Bell's Palsy Management
Immediate Pharmacologic Treatment
Start oral corticosteroids within 72 hours of symptom onset—this is the only proven treatment that significantly improves facial nerve recovery, and delaying beyond this window provides no benefit. 1
Recommended Steroid Regimens
Choose one of these evidence-based options:
- Prednisolone 50 mg once daily for 10 days (no taper required), OR
- 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
Evidence of benefit: 83% complete recovery at 3 months with steroids versus 64% with placebo (NNT = 6), and 94% recovery at 9 months versus 82% with placebo 1
Antiviral Therapy: Limited Role
Never prescribe antivirals alone—they are completely ineffective as monotherapy. 1
You may optionally add an antiviral to steroids within 72 hours for severe cases, though the incremental benefit is small (96.5% recovery versus 89.7% with steroids alone, absolute benefit +6.8%): 1
- Valacyclovir 1000 mg three times daily for 7 days, OR 1
- Acyclovir 400 mg five times daily for 10 days 1
The large BELLS trial (n=496) found no statistically significant advantage: 71% recovery with acyclovir versus 76% without (P=0.50) at 3 months 1
Special Populations
Diabetes is NOT a contraindication to steroids—the therapeutic benefit outweighs temporary hyperglycemia risk. Monitor capillary glucose every 2-4 hours during the first few days, dose steroids in the morning, and proactively increase basal and prandial insulin. 1
Pregnant women should receive oral corticosteroids within 72 hours after individualized risk-benefit discussion. 1
Children have better spontaneous recovery rates (up to 90%), but steroid benefit in pediatrics remains unproven. Consider steroids for severe/complete paralysis with substantial caregiver involvement in shared decision-making. 1
Eye Protection: Critical for All Patients with Incomplete Closure
Implement aggressive eye protection immediately to prevent corneal damage—this is mandatory, not optional. 1
Layered Protection Strategy
Apply all of the following measures simultaneously: 1
- Lubricating ophthalmic drops every 1-2 hours while awake 1
- Ophthalmic ointment at bedtime for sustained moisture 1
- Eye taping or patching at night (instruct carefully on proper technique to avoid corneal abrasion) 1
- Sunglasses outdoors to shield against wind and debris 1
- Moisture chambers (polyethylene covers) for severe cases 1
Urgent Ophthalmology Referral Triggers
Refer immediately if the patient develops: 1
- Eye pain, visual changes, or redness
- Discharge or foreign body sensation
- Complete inability to close the eye
- Any signs of corneal exposure or damage
For persistent lagophthalmos beyond 3 months, consider surgical options (tarsorrhaphy, eyelid weight implantation) or botulinum toxin injections. 1
Diagnostic Testing: What NOT to Do
Do not order routine laboratory tests or imaging for typical Bell's palsy—they delay treatment beyond the critical 72-hour window without improving outcomes. 1
Do not perform electrodiagnostic testing in patients with incomplete facial paralysis—it provides no actionable information. 1
You may offer electrodiagnostic testing (ENoG/EMG) to patients with complete paralysis, ideally 3-14 days after onset. Greater than 10% nerve response amplitude predicts excellent prognosis; less than 10% carries up to 50% risk of incomplete recovery. 1
Red Flags Requiring MRI with Contrast
Order MRI (with and without contrast) immediately if any of these atypical features are present: 1
- Recurrent paralysis on the same side (suggests tumor)
- Isolated branch paralysis (e.g., only lower face)
- Other cranial nerve involvement (indicates central or skull-base disease)
- Bilateral facial weakness (rare in Bell's palsy)
- Forehead sparing (classic sign of central stroke, not Bell's palsy)
- Progressive weakness beyond 3 weeks
- No recovery after 3 months
- New or worsening neurologic findings at any time
A second episode within one month is highly atypical and requires same-day or next-day specialist referral—do not reassure the patient this is "just another Bell's palsy" until alternative causes are excluded. 2
Follow-Up and Specialist Referral
Mandatory Reassessment Timeline
Refer to a facial nerve specialist if facial recovery is incomplete at 3 months after symptom onset. 1
Refer immediately at any time for: 1
- New or worsening neurologic findings
- Development of ocular symptoms
- Progressive weakness beyond 3 weeks
Early Follow-Up (1-2 Weeks)
Schedule early reassessment to: 1
- Monitor recovery trajectory
- Reinforce eye protection technique
- Identify early complications
- Provide psychological support
Therapies NOT Recommended
Do not prescribe physical therapy or acupuncture as primary treatment—no high-quality evidence supports benefit over spontaneous recovery in acute Bell's palsy. 1 3
There is low-quality evidence that tailored facial exercises may help chronic cases (>3 months) with persistent weakness, but this does not apply to acute management. 3
Do not perform surgical decompression except in rare, highly selected cases at specialized centers. 1
Common Pitfalls to Avoid
- Using a standard methylprednisolone dose pack delivers only ~105 mg prednisone-equivalent total versus the required ~540 mg—this is severe underdosing 1
- Delaying treatment to await test results compromises the 72-hour therapeutic window 1
- Prescribing antivirals alone is completely ineffective and delays appropriate steroid therapy 1
- Failing to test forehead function can miss central stroke (which spares the forehead) 1
- Inadequate eye protection monitoring leads to permanent corneal damage 1
- Failing to refer at 3 months delays access to reconstructive options for the 30% who develop permanent weakness 1
Natural History and Prognosis
Most patients (70-94%) achieve complete recovery within 3-4 months, with signs of improvement typically beginning within 2-3 weeks. 1
Patients with incomplete paralysis at presentation have excellent prognosis (up to 94% recovery), while those with complete paralysis have ~70% complete recovery rates. 1
Approximately 30% may experience permanent facial weakness with muscle contractures, synkinesis, or other sequelae requiring long-term management. 1