A patient with Bell’s palsy who has completed a 7‑day course of oral acyclovir and a 2‑week course of oral prednisone (60 mg daily with taper) still has significant facial asymmetry; what is the next appropriate management?

Continue Supportive Care and Monitor for Recovery

For a Bell's palsy patient who has completed standard treatment (acyclovir 7 days, prednisone 2 weeks) with noted improvement but persistent facial asymmetry at approximately 3 weeks, the appropriate next step is to continue aggressive eye protection, provide reassurance about the expected recovery timeline, and schedule reassessment at 3 months—not to restart or extend corticosteroids or antivirals. 1

Why No Additional Pharmacologic Therapy

• Do not restart or extend corticosteroid therapy beyond the initial 10-day course, as evidence supports only the initial treatment window within 72 hours of symptom onset. 1, 2 Initiating steroids after this critical window provides no proven benefit and exposes patients to medication risks without efficacy. 3

• Do not prescribe additional antiviral therapy, as acyclovir alone is ineffective as monotherapy and has no role after the initial treatment period. 1, 2 The combination of antivirals with steroids is only beneficial when started within 72 hours of onset. 1

Expected Recovery Timeline and Reassurance

• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset, with complete recovery typically occurring within 3-4 months. 1, 2 Your patient's noted improvement at 3 weeks is consistent with normal recovery trajectory.

• Approximately 70% of patients with complete paralysis recover facial function completely within 6 months, while patients with incomplete paralysis have even higher recovery rates up to 94%. 1, 2

• With corticosteroid treatment initiated within 72 hours (which your patient received), 83% recover at 3 months and 94.4% recover at 9 months. 1, 2 The fact that improvement is already noted is a positive prognostic sign.

Essential Ongoing Management

Eye Protection (Critical Priority)

• Continue aggressive eye protection measures to prevent corneal damage, even if the patient's primary concern is facial asymmetry rather than eye symptoms. 1, 2

• Apply lubricating ophthalmic drops every 1-2 hours while awake for sustained hydration. 1

• Use ophthalmic ointment at bedtime for overnight moisture retention. 1

• Implement eye taping or patching at night with proper technique to avoid corneal abrasion. 1

• Advise sunglasses outdoors to shield against wind and debris. 1

Pain Management (If Needed)

• Consider gabapentin 1800-3600 mg/day divided three times daily if the patient develops persistent neuropathic facial pain. 2 This addresses nerve pain without interfering with recovery.

Physical Therapy Consideration

• Physical therapy may be beneficial for patients with more severe paralysis and those developing synkinesis (involuntary co-contraction of facial muscles). 2, 4 However, evidence for specific protocols is limited. 1

Mandatory Reassessment Timeline

Three-Month Checkpoint

• Schedule reassessment or specialist referral at 3 months after initial symptom onset if facial recovery remains incomplete. 1, 2 This is a mandatory guideline recommendation, not optional. 1

• Use the House-Brackmann facial nerve grading system to objectively document recovery progress at follow-up visits. 1, 2

Urgent Reassessment Triggers (Before 3 Months)

Refer immediately to a facial nerve specialist if any of the following develop: 1, 2

• New or worsening neurologic findings at any point
• Development of ocular symptoms (eye pain, vision changes, redness, discharge)
• Progressive weakness beyond 3 weeks (suggests alternative diagnosis)
• Any additional cranial nerve involvement

Red Flags That Would Change Management

The following features would indicate this is NOT typical Bell's palsy and require immediate imaging (MRI with/without contrast) and specialist referral: 1

• Recurrent paralysis on the same side
• Isolated branch paralysis (only lower face affected)
• Bilateral facial weakness
• Forehead sparing (suggests central stroke, not Bell's palsy)
• Other cranial nerve involvement
• Progressive weakness beyond the expected recovery timeline

Common Pitfalls to Avoid

• Do not order routine laboratory tests or imaging at this stage for typical Bell's palsy with expected recovery trajectory. 1 This delays appropriate management without improving outcomes.

• Do not neglect eye protection even if the patient's primary complaint is cosmetic facial asymmetry rather than eye symptoms. 2 Corneal damage can occur silently.

• Do not fail to document baseline facial nerve function using a standardized grading system, as this is essential for tracking recovery and determining need for specialist referral at 3 months. 1, 2

• Do not provide false reassurance that recovery will be 100% complete—approximately 30% of patients may experience permanent facial weakness with muscle contractures. 1, 2

Patient Education Points

• Explain that persistent facial asymmetry at 3 weeks is normal and does not indicate treatment failure, as most patients continue improving for 3-4 months. 1, 2

• Emphasize the critical importance of continued eye protection until complete eye closure is restored. 1

• Set realistic expectations that while most patients recover completely, some degree of permanent weakness or synkinesis may persist in approximately 30% of cases. 1

• Provide clear instructions to return immediately for any new neurologic symptoms, worsening weakness, or eye problems. 1, 2