Bell's Palsy Treatment
Immediate Treatment: Corticosteroids Within 72 Hours
Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—this is the only treatment proven to significantly improve recovery, with 83% achieving complete recovery at 3 months versus 64% with placebo. 1
Corticosteroid Regimens (Choose One)
- Prednisolone 50 mg once daily for 10 days (no taper required) 1
- Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily for 5 days (total 10 days) 1
Evidence Supporting Steroids
- At 3 months: 83% complete recovery with prednisolone versus 63.6% with placebo (NNT = 6) 1
- At 9 months: 94.4% complete recovery with prednisolone versus 81.6% with placebo (NNT = 8) 1
- Treatment beyond 72 hours has no proven benefit and should not be initiated 2, 3
Antiviral Therapy: Optional Adjunct Only
Never prescribe antivirals alone—they are completely ineffective as monotherapy and delay appropriate corticosteroid treatment. 1, 3
When to Consider Adding Antivirals
- May add to corticosteroids within 72 hours for severe or complete paralysis after shared decision-making with the patient 1
- Modest incremental benefit: 96.5% recovery with combination therapy versus 89.7% with steroids alone (absolute benefit +6.8%) 4
- This is classified as an "option" rather than a recommendation due to the small benefit 1
Antiviral Regimens (If Used)
- Valacyclovir 1,000 mg three times daily for 7 days 1, 5
- Acyclovir 400 mg five times daily for 10 days 1, 5
Eye Protection: Mandatory for All Patients with Incomplete Eye Closure
Implement aggressive eye protection immediately to prevent permanent corneal damage—this is non-negotiable for any patient who cannot fully close the affected eye. 1, 3
Daytime Protection
- Lubricating ophthalmic drops every 1–2 hours while awake 1, 3
- Sunglasses outdoors to protect against wind, debris, and UV exposure 1, 3
Nighttime Protection
- Ophthalmic ointment at bedtime for sustained moisture retention 1, 3
- Eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 1, 3
- Moisture chambers using polyethylene covers for severe cases 1
Urgent Ophthalmology Referral Triggers
- Severe impairment with 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
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, 3
Testing NOT Recommended
- Routine laboratory studies 1, 3
- Routine CT or MRI imaging 1, 3
- Electrodiagnostic testing for incomplete facial paralysis 1, 3
When to Order MRI (With and Without Contrast)
Order imaging only for atypical features suggesting an alternative diagnosis: 1, 3
- Recurrent paralysis on the same side
- Isolated branch paralysis (e.g., only lower face affected)
- 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
Follow-Up and Referral
Mandatory 3-Month Reassessment
Refer to a facial nerve specialist if facial recovery is incomplete at 3 months after symptom onset. 1, 3
Urgent Referral Triggers (At Any Time)
- New or worsening neurologic findings 1, 3
- Development of ocular symptoms 1, 3
- Progressive weakness beyond 3 weeks 1
Expected Recovery Timeline
- Most patients begin showing recovery within 2–3 weeks 1, 2
- Complete recovery typically occurs within 3–4 months 1
- Patients with incomplete paralysis: up to 94% complete recovery 1, 2
- Patients with complete paralysis: approximately 70% complete recovery within 6 months 1, 2
Special Populations
Children
- Better prognosis than adults with higher spontaneous recovery rates (up to 90%) 2, 5
- Evidence for corticosteroid benefit in children is inconclusive 1
- Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 1, 3
- Dosing: prednisolone 1 mg/kg/day (maximum 50–60 mg) for 5 days, then 5-day taper 1
Pregnant Women
- Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 3
- Recovery rates up to 90% 5
- Eye protection measures are essential and safe in pregnancy 1
Patients with Diabetes
- Diabetes is not a contraindication to corticosteroid therapy 1
- Monitor capillary blood glucose every 2–4 hours during the first few days of steroid therapy 1
- Proactively adjust diabetes medications: increase basal insulin and add or increase prandial insulin 1
- The therapeutic benefit of corticosteroids outweighs the risk of temporary hyperglycemia 1
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours eliminates the proven benefit of corticosteroids 2, 3
- Using antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 3
- Inadequate eye protection can lead to permanent corneal damage 1, 3
- Failing to refer at 3 months delays access to reconstructive options 1, 3
- Ordering unnecessary labs or imaging increases cost and delays treatment without benefit 1, 3
- Using a standard methylprednisolone dose pack provides only 105 mg prednisone-equivalent versus the required 540 mg over 10–14 days—this represents significant underdosing 1
Treatments NOT Recommended
Do not offer the following interventions—they lack proven benefit: 1, 6