What is the recommended initial management of acute Bell's palsy, including corticosteroid dosing, antiviral use, eye protection, and follow‑up?

Management of Bell's Palsy

Immediate Treatment: Corticosteroids Within 72 Hours

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

Corticosteroid Dosing Regimens

Choose one of these evidence-based options:

• Prednisolone 50 mg once daily for 10 days (no taper required), OR 1, 2
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily (50→40→30→20→10 mg) over the next 5 days, stopping on day 11 1, 2

Critical timing: Treatment must begin within 72 hours of symptom onset—there is zero benefit beyond this window. 1, 3

Avoid this pitfall: Standard methylprednisolone dose packs deliver only ~105 mg prednisone-equivalent total versus the required ~540 mg, representing dangerous underdosing. 2

Antiviral Therapy: Minimal Role

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

Optional combination therapy: You 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, but the added benefit is minimal (96.5% vs 89.7% recovery, absolute benefit +6.8%). 1, 2 The large BELLS trial found no statistically significant advantage (71.2% vs 75.7%, P=0.50). 2

Mandatory Eye Protection for All Patients with Impaired Eye Closure

Implement aggressive eye protection immediately to prevent permanent corneal damage:

Daytime Measures

• Lubricating eye drops every 1-2 hours while awake 1, 2, 3
• Sunglasses outdoors to protect against wind and particles 1, 2

Nighttime Measures

• Ophthalmic ointment at bedtime for sustained moisture 1, 2, 3
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 2

Urgent ophthalmology referral required for: severe impairment with complete inability to close the eye, signs of corneal exposure or damage, or persistent lagophthalmos beyond 3 months. 2

Initial Diagnostic Assessment

Bell's palsy is a diagnosis of exclusion requiring focused history and physical examination to rule out alternative causes:

Key Physical Examination Findings

• Forehead involvement (inability to wrinkle forehead or raise eyebrow) is mandatory—forehead sparing indicates central stroke, not Bell's palsy 2, 3
• Complete cranial nerve examination—any additional cranial nerve deficit excludes Bell's palsy and mandates imaging 2
• Document severity using House-Brackmann grading scale (grades 1-6) 1, 2

Red Flags Requiring MRI with Contrast

Order MRI (with and without contrast) if any of these atypical features are present:

• Bilateral facial weakness 1, 2
• Isolated branch paralysis (e.g., only lower face) 1, 2
• Other cranial nerve involvement 1, 2
• Recurrent paralysis on the same side 1, 2
• Progressive weakness beyond 3 weeks 1, 2
• No recovery after 3 months 1, 2

What NOT to Order

Do not obtain routine laboratory tests or imaging for typical Bell's palsy—this delays treatment beyond the critical 72-hour window without improving outcomes. 1, 2, 3

Do not perform electrodiagnostic testing in patients with incomplete facial paralysis—it provides no actionable information. 1, 2 Consider it only for complete paralysis, ideally 3-14 days post-onset. 2

Follow-Up Schedule

Early Reassessment (1-2 Weeks)

Monitor recovery progress, reinforce eye protection, and identify complications. 1

Mandatory Reassessment or Specialist Referral at 3 Months

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months—approximately 30% of patients may have permanent facial weakness requiring long-term management including reconstructive surgery, ophthalmology care for persistent eye closure problems, and psychological support. 1, 2, 3

Urgent Referral Triggers at Any Time

• New or worsening neurologic findings 1, 2
• Development of ocular symptoms (eye pain, vision changes, redness, discharge) 1, 2

Special Populations

Children

• Better prognosis with up to 90% spontaneous recovery 1, 4
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, though pediatric evidence is less conclusive than adult data 1, 2, 3
• Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treating 2

Pregnant Women

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

Patients with Diabetes

Diabetes is not a contraindication to corticosteroids—the therapeutic benefit outweighs the risk of temporary hyperglycemia. 2 Monitor capillary blood glucose every 2-4 hours during the first few days, give steroids in the morning to align with natural cortisol rhythm, and proactively increase basal and prandial insulin doses. 2

Therapies NOT Recommended

Do not offer these interventions—they have no proven benefit or insufficient evidence:

• Physical therapy 1, 2
• Acupuncture 1, 2
• Surgical decompression (except rare cases at specialized centers) 1, 2
• Electrodiagnostic testing for incomplete paralysis 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3
• Inadequate eye protection monitoring can lead to permanent corneal damage, particularly with severe lagophthalmos 1, 2
• 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
• Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2

Prognosis

• Incomplete paralysis: up to 94% complete recovery 1, 2
• Complete paralysis: approximately 70% complete recovery within 6 months 1, 2
• Most patients begin showing recovery within 2-3 weeks 1
• With prednisolone treatment: 83% recovery at 3 months vs 63.6% with placebo; 94.4% recovery at 9 months vs 81.6% with placebo 1, 2