What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—this is the only proven treatment that significantly improves facial nerve recovery. 1, 2, 3

Corticosteroid Therapy (The Cornerstone of Treatment)

Timing is everything: Corticosteroids must be initiated within 72 hours of symptom onset. 1, 2, 3 After this window, there is no evidence of benefit and treatment should not be started. 1

Recommended regimens:

• Prednisolone 50 mg once daily for 10 days (no taper needed), OR 2, 3
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily for 5 days (total 10 days) 1, 2, 3

Evidence of benefit: 83% of patients recover completely at 3 months with prednisolone versus 63.6% with placebo (NNT = 6), and 94.4% recover at 9 months versus 81.6% with placebo. 2, 3

Special populations requiring individualized assessment:

• Diabetes mellitus: Steroids are NOT contraindicated—the benefit outweighs temporary hyperglycemia. 2 Monitor blood glucose every 2-4 hours during the first few days and proactively increase insulin doses. 2
• Pregnancy: Treat with corticosteroids within 72 hours after careful risk-benefit discussion. 1, 2, 3
• Children: Evidence for steroid benefit is less conclusive, but may consider on a case-by-case basis with caregiver involvement, as spontaneous recovery rates approach 90%. 2, 3

Antiviral Therapy (Optional Adjunct Only)

Never prescribe antivirals alone—they are completely ineffective as monotherapy. 1, 2, 3, 4

Combination therapy (steroids + antivirals) may be offered within 72 hours as an option for patients with severe paralysis, though the added benefit is small (96.5% recovery versus 89.7% with steroids alone). 2, 3

If using combination therapy:

• Valacyclovir 1 g three times daily for 7 days, OR 2, 4
• Acyclovir 400 mg five times daily for 10 days 2, 4

The American Academy of Otolaryngology-Head and Neck Surgery classifies this as an "option" rather than a recommendation due to the modest incremental benefit. 2

Eye Protection (Mandatory for All Patients with Incomplete Eye Closure)

Implement aggressive eye protection immediately to prevent corneal damage—this is non-negotiable. 1, 2, 3

Daytime protection:

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

Nighttime protection:

• 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, 3
• Moisture chambers using polyethylene covers for severe cases 1, 2

Urgent ophthalmology referral if:

• Complete inability to close the eye 2
• Eye pain, vision changes, redness, discharge, or foreign body sensation 2
• Signs of corneal exposure or damage 2

What NOT to Do

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

Do not prescribe:

• Antiviral monotherapy (completely ineffective) 1, 2, 3
• Physical therapy as primary treatment (no proven benefit over spontaneous recovery) 2, 4
• Acupuncture (poor-quality evidence, no recommendation possible) 2, 3
• Surgical decompression (rarely indicated except in specialized centers) 2, 3

Do not use a standard methylprednisolone dose pack—it provides only 105 mg prednisone-equivalent versus the required 540 mg total exposure, representing significant underdosing. 2

Follow-Up and Referral Triggers

Mandatory reassessment or specialist referral at 3 months if facial recovery is incomplete. 1, 2, 3

Immediate reassessment or referral if:

• New or worsening neurologic findings at any point 1, 2, 3
• Development of ocular symptoms at any point 1, 2, 3
• Progressive weakness beyond 3 weeks 2

Expected recovery timeline:

• Most patients begin showing recovery within 2-3 weeks 1, 2
• Complete recovery typically occurs within 3-4 months 1, 2
• 70% of patients with complete paralysis recover fully within 6 months even without treatment 1, 2
• Patients with incomplete paralysis have recovery rates up to 94% 1, 2

Red Flags Requiring Imaging (MRI with and without contrast)

Order MRI immediately if any of these features are present:

• Recurrent paralysis on the same side 2
• Isolated branch paralysis (e.g., only lower face) 2
• Involvement of other cranial nerves 2
• Bilateral facial weakness 2
• Forehead sparing (suggests central stroke, not Bell's palsy) 2
• Progressive weakness beyond 3 weeks 2
• No recovery after 3 months 1, 2

Common Pitfalls to Avoid

• Starting steroids after 72 hours provides no benefit and exposes patients to medication risks unnecessarily. 1, 2
• Failing to provide adequate eye protection can lead to permanent corneal damage. 1, 2, 3
• Delaying treatment to await unnecessary lab results or imaging compromises the 72-hour window. 2
• Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction. 1, 2
• Missing atypical features (bilateral weakness, other cranial nerve involvement, forehead sparing) delays diagnosis of alternative etiologies like stroke or tumor. 2