Treatment of Bell's Palsy
Immediate First-Line Treatment
Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the only proven effective treatment that significantly improves facial nerve recovery. 1, 2
Recommended Steroid Regimens
Choose one of the following evidence-based regimens, initiated within the critical 72-hour window:
- Prednisolone 50 mg once daily for 10 days (no taper required), OR 1, 2
- Prednisone 60 mg once daily for 5 days, followed by a 5-day taper 1, 2
The evidence supporting early corticosteroids is robust: 83% of patients achieve complete recovery at 3 months with prednisolone versus only 63.6% with placebo (NNT = 6), and 94.4% recover by 9 months versus 81.6% with placebo. 1
Critical Timing Considerations
Do not initiate corticosteroids if the patient presents beyond 72 hours of symptom onset—the evidence demonstrates no benefit after this window, and you would expose the patient to medication risks without therapeutic gain. 3, 1 Clinical trials demonstrating steroid efficacy specifically enrolled patients within 72 hours, with no high-quality evidence supporting later administration. 3
Antiviral Therapy: When and How to Use
Never prescribe antiviral monotherapy alone—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 4
Optional Combination Therapy
You may consider adding an antiviral to corticosteroids within 72 hours for patients with severe or complete paralysis, though the added benefit is modest (absolute improvement of approximately 6.8%): 1, 2
- Valacyclovir 1000 mg three times daily for 7 days, OR 1, 4
- Acyclovir 400 mg five times daily for 10 days 1, 4
The American Academy of Otolaryngology-Head and Neck Surgery classifies this as an "option" rather than a recommendation because the incremental benefit is small—one study showed 96.5% recovery with combination therapy versus 89.7% with steroids alone, but the large BELLS trial found no statistically significant advantage. 1
Essential Eye Protection (All Patients with Incomplete Eye Closure)
Implement comprehensive eye protection immediately to prevent corneal damage—this is mandatory for any patient who cannot fully close the affected eye: 3, 1
Daytime Protection
- Lubricating ophthalmic drops every 1-2 hours while awake 3, 1
- Sunglasses outdoors to protect against wind and foreign particles 3, 1
Nighttime Protection
- Ophthalmic ointment at bedtime for sustained moisture retention 3, 1
- Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 3, 1
- Moisture chambers using polyethylene covers for severe cases 3
Urgent Ophthalmology Referral Triggers
Refer immediately if the patient develops: 3, 1
- Eye pain or changes in vision
- Redness, discharge, or sensation of foreign body
- Severe impairment with complete inability to close the eye
- Any signs of corneal exposure or damage
Diagnostic Testing: What NOT to Do
Do not order routine laboratory tests or imaging for typical Bell's palsy presentations—they delay treatment without improving outcomes and are explicitly not recommended. 1, 2 The diagnosis is clinical, based on acute unilateral facial weakness involving the forehead with onset under 72 hours and no other identifiable cause. 1
When to Consider Imaging
Reserve MRI with and without contrast only for atypical presentations: 3, 1
- Recurrent paralysis on the same side
- Isolated branch paralysis (not involving forehead)
- Other cranial nerve involvement
- Bilateral facial weakness
- Progressive weakness beyond 3 weeks
- No sign of recovery after 3 months
Do not perform electrodiagnostic testing in patients with incomplete facial paralysis—it provides no actionable information. 1
Follow-Up and Referral Algorithm
Mandatory 3-Month Reassessment
Refer to a facial nerve specialist if facial recovery remains incomplete at 3 months after symptom onset—approximately 30% of patients may experience permanent facial weakness requiring reconstructive evaluation. 3, 1, 2
Urgent Referral Triggers (At Any Time)
Refer immediately for: 3, 1, 2
- New or worsening neurologic findings (suggests alternative diagnosis such as stroke, tumor, or CNS pathology)
- Development of ocular symptoms (risk of permanent corneal damage)
- Progressive weakness beyond 3 weeks (red flag for non-Bell's palsy etiology)
Expected Recovery Timeline
Most patients begin showing signs of recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 3, 1 Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment, while those with incomplete paralysis have recovery rates up to 94%. 3, 1
Special Populations
Children
- Higher spontaneous recovery rates (up to 90%) than adults 1, 4
- Evidence for corticosteroid benefit is less conclusive in pediatrics 1, 2
- Consider oral steroids on an individualized basis with caregiver involvement in shared decision-making 1
- Same eye protection measures apply 3
Pregnant Women
- Treat with oral corticosteroids within 72 hours after individualized risk-benefit assessment 1
- The therapeutic benefit typically outweighs risks in this population 1
- Eye protection measures are essential and safe in pregnancy 1
Patients with Diabetes
- Diabetes is not a contraindication to corticosteroids—the therapeutic benefit outweighs the risk of temporary hyperglycemia 1
- Monitor capillary blood glucose every 2-4 hours during the first few days of steroid therapy 1
- Proactively adjust diabetes medications: increase basal insulin and add or increase prandial insulin as needed 1
- Consider adding NPH insulin concurrent with morning steroid dose (peaks 4-6 hours later, matching hyperglycemic effect) 1
Common Pitfalls to Avoid
Starting steroids beyond 72 hours—provides minimal benefit and exposes patients to medication risks without therapeutic gain 3, 1
Prescribing antiviral monotherapy—completely ineffective and delays appropriate corticosteroid treatment 1, 2, 4
Inadequate eye protection—failing to provide comprehensive eye care for patients with impaired eye closure can lead to permanent corneal damage 3, 1, 2
Ordering unnecessary tests—routine laboratory testing and imaging delay treatment without improving outcomes in typical presentations 1, 2
Missing atypical features—bilateral weakness, isolated branch paralysis, other cranial nerve involvement, or progressive weakness beyond 3 weeks all suggest alternative diagnoses requiring different management 3, 1
Failing to refer at 3 months—delays access to reconstructive options and psychological support for patients with incomplete recovery 3, 1