What is the recommended acute management of Bell's palsy, including corticosteroid regimen, antiviral therapy indications, eye protection measures, and dose adjustments for patients with diabetes, hypertension, or peptic ulcer disease?

Treatment of Bell's Palsy

Immediate Corticosteroid Therapy (Within 72 Hours)

Start oral prednisolone 50 mg once daily for 10 days (no taper) OR prednisone 60 mg once daily for 5 days followed by 50→40→30→20→10 mg on days 6-10, but ONLY if the patient presents within 72 hours of symptom onset. 1

Evidence for Corticosteroids

• Prednisolone achieves 83% complete recovery at 3 months versus 63.6% with placebo (absolute benefit 19.4%, NNT=6), and 94.4% recovery at 9 months versus 81.6% with placebo 1, 2
• Treatment initiated beyond 72 hours has no proven benefit and should generally be avoided 1, 3
• The 72-hour window exists because early treatment reduces facial nerve inflammation before permanent damage occurs 3

Dosing Details

• Give the entire daily dose as a single morning dose, not split throughout the day 1
• Maximum daily dose is 60 mg prednisone (or 50 mg prednisolone) 1
• Avoid standard methylprednisolone dose packs—they deliver only ~105 mg prednisone-equivalent total versus the required ~540 mg over 10 days, representing significant underdosing 1

Antiviral Therapy: Limited Role

Do NOT prescribe antiviral monotherapy—it is completely ineffective and delays appropriate steroid treatment. 1, 2

Optional Combination Therapy

• You may consider adding valacyclovir 1000 mg three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours for severe/complete paralysis 1, 4
• The incremental benefit is small: one trial showed 96.5% recovery with combination versus 89.7% with steroids alone (absolute benefit 6.8%) 1, 4
• However, the largest high-quality trial (BELLS study, n=496) found no statistically significant advantage: 71.2% recovery with acyclovir versus 75.7% without at 3 months (P=0.50) 1, 2
• This remains an "option" for shared decision-making, not a formal recommendation 1

Eye Protection: Mandatory for All Patients with Incomplete Eye Closure

Implement aggressive eye protection immediately to prevent corneal damage—this is non-negotiable regardless of treatment timing. 1

Daytime Protection

• Apply lubricating ophthalmic drops (e.g., hydroxypropyl methylcellulose) every 1-2 hours while awake 1
• Prescribe sunglasses for outdoor use to shield against wind and debris 1

Nighttime Protection

• Apply ophthalmic ointment at bedtime for sustained moisture retention 1
• Use eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral Triggers

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Any signs of corneal exposure or damage 1

Management for Patients Presenting After 72 Hours

If the patient presents on day 5 or later, do NOT initiate corticosteroids—focus entirely on eye protection and monitoring for recovery. 3

• The evidence supporting steroids specifically enrolled patients within 72 hours; no high-quality data support later initiation 3
• Approximately 70% of patients with complete paralysis and 94% with incomplete paralysis recover spontaneously without treatment 3
• Most patients begin showing recovery within 2-3 weeks 3

Special Population: Diabetes Mellitus

Diabetes is NOT a contraindication to corticosteroids—the therapeutic benefit outweighs the risk of temporary hyperglycemia. 1

Glucose Management During Steroid Therapy

• Monitor capillary blood glucose every 2-4 hours during the first few days 1
• Give steroids in the morning to align with natural cortisol rhythm; this causes disproportionate daytime hyperglycemia that is easier to manage 1
• Proactively increase basal insulin dose and add or increase prandial insulin 1
• For patients on oral agents, add NPH insulin concurrent with the morning steroid dose—NPH peaks 4-6 hours later, matching the hyperglycemic effect 1

Special Population: Hypertension

• Hypertension is a risk factor for Bell's palsy but is NOT a contraindication to short-course corticosteroids 1
• Monitor blood pressure during treatment; the 10-day course rarely causes clinically significant hypertensive crises 1

Special Population: Peptic Ulcer Disease

• Active or recent peptic ulcer disease requires individualized assessment 1
• Consider adding a proton pump inhibitor during the steroid course 1
• The short 10-day duration minimizes GI risk compared to chronic steroid use 1

Special Population: Pregnancy

Treat pregnant women with oral corticosteroids within 72 hours after individualized risk-benefit discussion. 1

• The same prednisolone/prednisone regimens apply 1
• Eye protection measures are essential and safe in pregnancy 1

Diagnostic Testing: What NOT to Do

Do NOT order routine laboratory tests or imaging for typical Bell's palsy—this delays treatment beyond the critical 72-hour window without improving outcomes. 1

When to Order MRI (with and without contrast)

Order imaging ONLY if any of these red flags are present: 1

• Recurrent paralysis on the same side
• Isolated branch paralysis (e.g., only lower face affected)
• Any other cranial nerve involvement
• Bilateral facial weakness
• Forehead sparing (suggests central stroke, not Bell's palsy)
• Progressive weakness beyond 3 weeks
• No recovery after 3 months
• New or worsening neurologic findings at any time

Electrodiagnostic Testing

• Do NOT perform electrodiagnostic testing in patients with incomplete facial paralysis 1
• May offer testing to patients with complete paralysis, ideally 3-14 days post-onset 1
• Testing before 7 days or after 14-21 days provides unreliable prognostic information 1

Mandatory Follow-Up and Referral Triggers

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months after symptom onset. 1

Urgent Referral at Any Time Point

• New or worsening neurologic findings 1
• Development of ocular symptoms (pain, vision changes, redness) 1
• Progressive weakness beyond 3 weeks 1

Therapies That Do NOT Work

Do NOT recommend or prescribe: 1

• Acupuncture (poor-quality trials, no proven benefit)
• Physical therapy (no evidence of benefit over spontaneous recovery)
• Surgical decompression (rarely indicated except in specialized centers for specific traumatic cases)

Common Pitfalls to Avoid

• Starting steroids after 72 hours exposes patients to medication risks without proven benefit 1, 3
• Using antiviral monotherapy is completely ineffective and delays appropriate treatment 1
• Inadequate eye protection can lead to permanent corneal damage, especially in patients with complete paralysis 1
• Failing to refer at 3 months delays access to reconstructive options for the 30% who develop permanent weakness 1
• Ordering unnecessary labs or imaging increases cost and delays treatment initiation 1