What is the recommended acute management for Bell's palsy, including corticosteroid and antiviral therapy, eye protection, facial exercises, and follow‑up?

Acute Management of Bell's Palsy

Start oral prednisolone 50 mg once daily for 10 days (or prednisone 60 mg daily for 5 days then taper over 5 days) immediately if the patient presents within 72 hours of symptom onset—this is the only proven treatment that significantly improves recovery. 1, 2, 3

Initial Assessment (Within 72 Hours)

Perform a focused examination to exclude alternative diagnoses before initiating treatment:

• Check forehead function: inability to wrinkle the forehead confirms peripheral (Bell's) palsy, whereas forehead sparing indicates central stroke requiring immediate imaging 1, 2, 3
• Test all other cranial nerves: any additional cranial nerve deficit excludes Bell's palsy and mandates MRI 1, 2
• Document severity using the House-Brackmann grading scale (Grade 1 = normal to Grade 6 = complete paralysis) 1
• Assess eye closure: incomplete closure requires immediate aggressive eye protection to prevent permanent corneal damage 1, 2, 3

Do NOT order routine laboratory tests or imaging for typical presentations—these delay treatment beyond the critical 72-hour window without improving outcomes. 1, 2, 3

Corticosteroid Therapy (First-Line Treatment)

Evidence supporting steroids: 83% complete recovery at 3 months with prednisolone versus 64% with placebo (NNT = 6), and 94% recovery at 9 months versus 82% with placebo. 1, 4

Dosing regimens (choose one):

• Prednisolone 50 mg once daily for 10 days (no taper needed) 1, 3
• Prednisone 60 mg once daily for 5 days, then 50 mg day 6,40 mg day 7,30 mg day 8,20 mg day 9,10 mg day 10 1, 3

Critical timing: Treatment must begin within 72 hours of symptom onset—there is zero benefit if started later. 1, 2, 3

Special Populations

• Diabetes: Corticosteroids are NOT contraindicated; monitor blood glucose every 2-4 hours during the first few days and adjust insulin proactively (increase basal and prandial doses). 1
• Pregnancy: Treat with oral corticosteroids within 72 hours after individualized risk-benefit discussion—the benefit of preventing permanent facial paralysis outweighs the minimal steroid risk. 1, 3
• Children: Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, though evidence is less robust than in adults (children have 90% spontaneous recovery rates). 1, 2, 3

Antiviral Therapy (Optional, Minimal Benefit)

Never prescribe antivirals alone—they are completely ineffective as monotherapy and delay appropriate corticosteroid treatment. 1, 2, 3, 4

Combination therapy (steroids + antivirals) may be offered within 72 hours for severe cases:

• Valacyclovir 1000 mg three times daily for 7 days, OR 1, 5
• Acyclovir 400 mg five times daily for 10 days 1, 5

The added benefit is small: 96.5% complete recovery with combination therapy versus 89.7% with steroids alone (absolute benefit +6.8%, NNT = 15). 1 The large BELLS trial found no statistically significant advantage at 3 months (71% vs 76%, p=0.50) or 9 months (85% vs 91%). 1

Mandatory Eye Protection (All Patients with Impaired Eye Closure)

Implement immediately to prevent corneal exposure keratitis and permanent damage:

Daytime measures:

• Lubricating eye drops (preservative-free artificial tears) every 1-2 hours while awake 1, 2, 3
• Sunglasses outdoors to protect against wind, particles, and UV exposure 1, 2, 3

Nighttime measures:

• Ophthalmic ointment (e.g., erythromycin or lacrilube) at bedtime for sustained moisture 1, 2, 3
• Eye taping or patching with careful instruction on proper technique—improper taping can cause corneal abrasion 1, 2
• Consider moisture chambers (polyethylene covers) for severe cases 1

Urgent ophthalmology referral if:

• Complete inability to close the eye 1
• Eye pain, redness, discharge, or vision changes 1
• Signs of corneal exposure or damage 1

Facial Exercises and Physical Therapy

Physical therapy is NOT recommended as routine treatment—there is no proven benefit over spontaneous recovery in randomized trials. 1, 2, 3 It may be considered for patients with severe paralysis (House-Brackmann Grade 5-6) but should not delay corticosteroid initiation. 5

Follow-Up Schedule

Early reassessment (1-2 weeks):

• Monitor recovery progress (most patients begin showing improvement within 2-3 weeks) 1, 3
• Reinforce eye protection techniques 1, 2
• Identify early complications or new neurologic findings 1, 2

Mandatory reassessment or specialist referral at 3 months if:

• Incomplete facial recovery (approximately 30% of patients have permanent weakness) 1, 2, 3
• New or worsening neurologic findings at any point 1, 2, 3
• Development of ocular symptoms at any point 1, 2, 3

Red Flags Requiring Immediate MRI and Specialist Referral

Order MRI with and without contrast if any of the following are present:

• Bilateral facial weakness 1, 2, 3
• Forehead sparing (suggests central stroke) 1, 2
• Isolated branch paralysis (e.g., only lower face affected) 1, 2
• Other cranial nerve involvement 1, 2, 3
• Recurrent paralysis on the same side 1, 2
• Progressive weakness beyond 3 weeks 1, 2
• Gradual onset over more than 72 hours 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3, 4
• Inadequate eye protection can lead to permanent corneal scarring and vision loss 1, 2, 3
• Ordering routine labs or imaging for typical presentations wastes time and money without improving outcomes 1, 2, 3
• Missing forehead involvement leads to misdiagnosis of stroke as Bell's palsy 1, 2, 3
• Failing to refer at 3 months delays access to reconstructive surgery (facial nerve reanimation procedures are most effective within 2 years) 1, 6

Therapies NOT Recommended

• Acupuncture: no recommendation can be made due to poor-quality trials 1, 2
• Surgical decompression: not indicated except in rare, highly selected cases at specialized centers 1, 2, 3
• Electrodiagnostic testing: not recommended for incomplete paralysis; may be offered for complete paralysis 3-14 days post-onset 1, 2