What is the recommended treatment for Bell's palsy?

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Treatment of Bell's Palsy

Immediate Treatment: Corticosteroids Within 72 Hours

All patients 16 years and older with Bell's palsy must receive oral corticosteroids within 72 hours of symptom onset—this is the single most important intervention that significantly improves complete recovery rates from 64% to 83% at 3 months and from 82% to 94% at 9 months. 1, 2

Recommended Corticosteroid Regimens

Choose one of these evidence-based options 1, 3, 4:

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

Critical timing: Treatment initiated beyond 72 hours provides no benefit—do not delay for laboratory tests or imaging in typical presentations. 1, 3, 4

Diabetes is NOT a Contraindication

Diabetic patients should receive corticosteroids; the therapeutic benefit outweighs temporary hyperglycemia risk. 1 Monitor capillary glucose every 2-4 hours during the first few days, dose steroids in the morning to align with natural cortisol rhythm, and proactively increase basal and prandial insulin. 1

Antiviral Therapy: Minimal Role

Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 3, 4, 2

Combination therapy (corticosteroids + antivirals) may be offered within 72 hours but provides only a small incremental benefit: 96.5% recovery versus 89.7% with steroids alone (absolute benefit +6.8%). 1 The large BELLS trial found no statistically significant advantage: 71.2% recovery with acyclovir versus 75.7% without at 3 months (P=0.50). 1, 2

If you choose to add an antiviral 1, 4:

  • Valacyclovir 1000 mg three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days

Mandatory Eye Protection for All Patients with Impaired Eye Closure

Implement aggressive eye protection immediately to prevent permanent corneal damage—this is non-negotiable. 1, 3, 4

Daytime Measures 1, 3, 4:

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

Nighttime Measures 1, 3, 4:

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

Urgent Ophthalmology Referral 1:

  • Severe impairment with complete inability to close the eye
  • Any signs of corneal exposure or damage (eye pain, vision changes, redness, discharge)

Initial Diagnostic Assessment: Exclude Alternative Causes

Bell's palsy is a diagnosis of exclusion—perform a focused examination to rule out stroke, tumor, infection, or trauma before initiating treatment. 1, 3, 4

Key Physical Examination Findings 1, 5:

Forehead involvement is mandatory: Inability to wrinkle the forehead or raise the eyebrow confirms peripheral (not central) facial palsy. Forehead sparing suggests stroke and requires immediate imaging. 1, 5

Complete cranial nerve examination: Any additional cranial nerve deficit excludes Bell's palsy and mandates neuroimaging. 1

Assess severity using House-Brackmann grading scale (Grade 1 = normal to Grade 6 = total paralysis). 1, 3

What NOT to Order 1, 3, 4:

Do not obtain routine laboratory tests or imaging for typical Bell's palsy presentations—these delay treatment beyond the critical 72-hour window without improving outcomes. 1, 3, 4

Red Flags Requiring MRI with Contrast

Order MRI (with and without contrast) immediately if any of these features are present 1, 3, 4:

  • Recurrent paralysis on the same side (suggests tumor)
  • Isolated branch paralysis (e.g., only lower face affected)
  • Bilateral facial weakness (rare in Bell's palsy)
  • Forehead sparing (indicates central stroke)
  • Other cranial nerve involvement (points to brainstem or skull-base disease)
  • Progressive weakness beyond 3 weeks (raises concern for neoplasm)
  • No recovery after 3 months (indicates possible non-idiopathic cause)
  • New or worsening neurologic findings at any time

Follow-Up and Specialist Referral

Early Reassessment at 1-2 Weeks 1, 3:

Monitor recovery progress, reinforce eye protection, and identify early complications.

Mandatory Referral at 3 Months 1, 3, 4:

Refer all patients with incomplete facial recovery at 3 months to a facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options. Approximately 30% of patients experience permanent facial weakness requiring long-term management. 1, 3

Urgent Reassessment Triggers (At Any Time) 1, 3, 4:

  • New or worsening neurologic findings
  • Development of ocular symptoms
  • Progressive weakness or pain after initial treatment

Special Populations

Children 1, 3, 4:

Children have better prognosis with up to 90-94% spontaneous recovery, but the benefit of corticosteroids in pediatrics is inconclusive. Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis after shared decision-making with caregivers, emphasizing that most children recover completely without treatment. 1, 4

Pregnancy 1, 3, 4:

Pregnant women should receive oral corticosteroids within 72 hours using individualized risk-benefit assessment. Eye protection measures are essential and safe in pregnancy. 1, 4

Therapies NOT Recommended

Do not offer the following interventions—they lack proven benefit or have insufficient evidence 1, 3, 4, 6:

  • Physical therapy (no proven benefit over spontaneous recovery) 1, 6
  • Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 6
  • Surgical decompression (rarely indicated except in highly selected cases at specialized centers) 1, 3
  • Electrodiagnostic testing for incomplete paralysis (provides no actionable information) 1

Common Pitfalls to Avoid

  • Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 3, 4
  • Prescribing antiviral monotherapy is completely ineffective 1, 2
  • Inadequate eye protection monitoring can cause permanent corneal damage 1, 3
  • Failing to refer at 3 months delays reconstructive options and psychological support 1, 3
  • Missing red flags (bilateral weakness, forehead sparing, other cranial nerve involvement) delays diagnosis of alternative etiologies 1, 5
  • Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 3

Prognosis

Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 1 Patients with incomplete paralysis at presentation have excellent prognosis (up to 94% complete recovery), while those with complete paralysis have approximately 70% complete recovery within 6 months. 1, 2

References

1
Guideline

Assessment and Management of Bell's Palsy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Research

Early treatment with prednisolone or acyclovir in Bell's palsy.

The New England journal of medicine, 2007

3
Guideline

Management of Bell's Palsy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Treatment of Bell's Palsy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Research

Bell's Palsy.

Continuum (Minneapolis, Minn.), 2017

6
Research

A general practice approach to Bell's palsy.

Australian family physician, 2016

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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