Treatment for Bell's Palsy

Immediate First-Line Treatment

Start oral corticosteroids immediately within 72 hours of symptom onset for all patients 16 years and older—this is the only proven effective treatment and significantly improves complete recovery from 64% to 83% at 3 months. 1, 2, 3

Corticosteroid Regimen (Choose One)

Prednisolone 50 mg once daily for 10 days (no taper required), OR 1, 2, 3
Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily for 5 days (total 10 days, stop on day 11) 1, 2, 3

Critical timing: Treatment beyond 72 hours provides no benefit—do not delay for laboratory tests or imaging in typical presentations. 1, 2, 3

Evidence strength: High-quality randomized controlled trials show 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo (number needed to treat = 8). 1, 4

Antiviral Therapy: Limited Role Only

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

Optional Combination Therapy

May add valacyclovir 1000 mg three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours 1, 5
The added benefit is minimal: 96.5% recovery with combination versus 89.7% with steroids alone (absolute benefit +6.8%) 1
The large BELLS trial showed no statistically significant advantage: 71.2% recovery with acyclovir versus 75.7% without (p=0.50) 1, 4
Classification: This is an "option" for shared decision-making, not a formal recommendation 1

Mandatory Eye Protection for All Patients with Impaired 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, 2, 3

Daytime Measures

Lubricating eye drops every 1–2 hours while awake (e.g., hydroxypropyl methylcellulose) 1, 2, 3
Sunglasses outdoors to protect against wind, particles, and irritants 1, 2, 3

Nighttime Measures

Ophthalmic ointment at bedtime for sustained moisture retention 1, 2, 3
Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2, 3
Moisture chambers (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
Signs of corneal exposure or damage 1

Diagnostic Assessment: What to Do and What to Avoid

Essential Clinical Examination

Test forehead function: Inability to wrinkle the forehead confirms peripheral (Bell's palsy) versus central (stroke) lesion—forehead sparing indicates stroke and requires immediate imaging 1, 3, 6
Complete cranial nerve examination: Any additional cranial nerve deficit excludes Bell's palsy and mandates MRI 1, 3
Document severity using House-Brackmann grading scale (1=normal to 6=total paralysis) 1, 2

Do NOT Order Routinely

No routine laboratory tests—they delay treatment beyond the critical 72-hour window without improving outcomes 1, 2, 3
No routine imaging (CT or MRI) for typical presentations 1, 2, 3
No electrodiagnostic testing for incomplete facial paralysis—it provides no actionable information 1, 2

Red Flags Requiring MRI with Contrast

Order MRI immediately if any of the following are present:

Recurrent paralysis on the same side 1, 2, 3
Isolated branch paralysis (e.g., only lower face) 1, 2, 3
Bilateral facial weakness 1, 2, 3
Other cranial nerve involvement 1, 2, 3
Forehead sparing (suggests stroke) 1, 3
Progressive weakness beyond 3 weeks 1, 2
No recovery after 3 months 1, 2, 3
New or worsening neurologic findings at any time 1, 2, 3

Follow-Up Schedule

Early Reassessment (1–2 Weeks)

Monitor recovery progress 2
Reinforce eye protection techniques 2
Identify early complications 2

Mandatory 3-Month Reassessment

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months—approximately 30% of patients may have permanent facial weakness requiring reconstructive options. 1, 2, 3

Urgent Reassessment Triggers (Any Time)

New or worsening neurologic findings 1, 2, 3
Development of ocular symptoms 1, 2, 3
Progressive weakness beyond expected timeline 1, 2

Special Populations

Children

Better prognosis: Up to 90% spontaneous recovery without treatment 1, 2, 5
Corticosteroid benefit is inconclusive in pediatric trials 1, 2
May consider prednisolone 1 mg/kg/day (maximum 50–60 mg) for severe or complete paralysis after shared decision-making with caregivers 1
Same 72-hour window applies if treatment is chosen 1

Pregnant Women

Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2, 3
Eye protection measures are essential and safe in pregnancy 1, 2
Combination therapy with antivirals may be considered on an individualized basis 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 1
Proactively adjust diabetes medications: increase basal insulin and add/increase prandial insulin to counter steroid-induced hyperglycemia 1
The therapeutic benefit outweighs the risk of temporary hyperglycemia 1

Prognosis and Natural History

Recovery Rates Without Treatment

Incomplete paralysis: Up to 94% complete recovery 1, 3
Complete paralysis: Approximately 70% complete recovery within 6 months 1, 3
Most patients begin recovery within 2–3 weeks 1, 3

With Corticosteroid Treatment

83% complete recovery at 3 months (versus 64% with placebo) 1, 4
94.4% complete recovery at 9 months (versus 81.6% with placebo) 1, 4

Therapies NOT Recommended

Do not offer the following—they have no proven benefit or insufficient evidence:

Physical therapy (no proven benefit over spontaneous recovery) 1, 2, 7
Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 7
Surgical decompression (rarely indicated except in specialized centers for specific cases) 1, 2
Electrotherapy (lacking well-designed studies) 7

Critical 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
Inadequate eye protection monitoring can lead to permanent corneal damage 1, 2, 3
Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 2, 3
Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2, 3
Ordering routine labs or imaging for typical presentations increases costs without benefit and delays treatment 1, 2, 3
Using standard methylprednisolone dose packs provides only 105 mg prednisone-equivalent versus the required 540 mg total exposure—this is significant underdosing 1

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