What is the recommended treatment for Bell's palsy?

Treatment of Bell's Palsy

Prescribe oral corticosteroids immediately for all patients ≥16 years presenting within 72 hours of symptom onset—this is the only proven effective treatment and significantly improves complete recovery rates from 64% to 83% at 3 months. 1, 2, 3

Immediate Corticosteroid Therapy (Within 72 Hours)

Choose one of these evidence-based regimens:

• Prednisolone 50 mg once daily for 10 days (no taper required), OR 1, 2, 4
• Prednisone 60 mg once daily for 5 days, followed by a 5-day taper 1, 2, 4

Critical timing considerations:

• Treatment must begin within 72 hours of symptom onset—there is no benefit beyond this window 1, 2, 4
• At 9 months, recovery rates reach 94.4% with prednisolone versus 81.6% without treatment 1, 3
• Delaying treatment beyond 72 hours eliminates the effectiveness of corticosteroid therapy entirely 1, 2, 4

Antiviral Therapy: Minimal Role

Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 4, 5, 6, 7

Optional combination therapy (small benefit only):

• May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours 1, 7
• The added benefit is minimal: 96.5% recovery with combination versus 89.7% with steroids alone (absolute benefit +6.8%) 1
• The large BELLS trial showed no statistically significant advantage: 71.2% recovery with acyclovir versus 75.7% without (P=0.50) 1, 3

Mandatory Eye Protection (All Patients with Impaired Eye Closure)

Implement aggressive eye protection immediately to prevent permanent corneal damage: 1, 2, 4

Daytime measures:

• Lubricating eye drops every 1-2 hours while awake 1, 2, 4
• Sunglasses outdoors to protect against wind and particles 1, 2, 4

Nighttime measures:

• Ophthalmic ointment at bedtime for sustained moisture 1, 2, 4
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2, 4
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent ophthalmology referral if:

• Severe impairment with complete inability to close the eye 1
• Signs of corneal exposure or damage develop 1
• Eye pain, vision changes, redness, or discharge occur 1

Initial Diagnostic Assessment

Perform focused examination to exclude alternative causes—Bell's palsy is a diagnosis of exclusion: 2, 4, 6

Key examination findings that confirm Bell's palsy:

• Acute unilateral facial weakness involving the forehead (distinguishes from stroke, which spares forehead) 1, 4, 6
• Symptom onset over 24-72 hours 1, 4
• No other cranial nerve involvement 1, 6
• Normal otoscopic findings, no skin lesions, no parotid masses 8

Red flags requiring imaging (MRI with/without contrast):

• Bilateral facial weakness 1, 2, 4
• Isolated branch paralysis (not diffuse nerve involvement) 1, 2, 4
• Other cranial nerve involvement 1, 2, 4
• Recurrent paralysis on the same side 1
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1, 2

Do NOT order:

• Routine laboratory testing—delays therapy without improving outcomes 1, 2, 4
• Routine imaging for typical presentations 1, 2, 4
• Electrodiagnostic testing for incomplete paralysis 1, 2

Follow-Up Schedule

Early reassessment at 1-2 weeks:

• Monitor recovery progress 2
• Reinforce eye protection measures 2
• Identify early complications 2

Mandatory reassessment or specialist referral at 3 months if:

• Facial recovery is incomplete 1, 2, 4
• New or worsening neurologic findings develop at any point 1, 2, 4
• Ocular symptoms develop at any point 1, 2, 4

Special Populations

Children:

• Better prognosis with up to 90% spontaneous recovery 2, 7
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 2, 4
• Evidence for steroid benefit in children is less conclusive than in adults 1

Pregnant women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2, 4
• Eye protection measures are essential and safe in pregnancy 1, 2

Diabetic patients:

• Diabetes is not a contraindication to corticosteroids 1
• Monitor blood glucose every 2-4 hours during first few days of steroid therapy 1
• Proactively adjust diabetes medications: increase basal insulin and add/increase prandial insulin 1
• The therapeutic benefit outweighs the risk of temporary hyperglycemia 1

Prognosis

Expected recovery timeline:

• Most patients begin showing recovery within 2-3 weeks 1, 4
• Complete recovery typically occurs within 3-4 months 1
• Incomplete paralysis: up to 94% complete recovery 1, 4
• Complete paralysis: approximately 70% complete recovery within 6 months 1, 4
• 30% may experience permanent facial weakness with muscle contractures 1, 2

Therapies NOT Recommended

Do not offer the following—no proven benefit or insufficient evidence:

• Physical therapy (no proven benefit over spontaneous recovery) 1, 2, 5
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 2, 5
• Surgical decompression (rarely indicated except in highly selected cases at specialized centers) 1, 2, 5
• Electrotherapy (lacking well-designed studies) 5

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2, 4
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 4, 7
• Inadequate eye protection monitoring can lead to permanent corneal damage 1, 2, 4
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 2
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2, 4, 6
• Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2, 4