How should Bell's palsy be treated?

Treatment of Bell's Palsy

All adults and adolescents ≥16 years with Bell's palsy should receive oral corticosteroids within 72 hours of symptom onset—this is the only treatment with strong evidence for improving facial nerve recovery and reducing long-term disability. 1

Core Treatment Algorithm

First-Line: Oral Corticosteroids (MANDATORY)

• Initiate within 72 hours of symptom onset for patients ≥16 years old
• Dosing regimens (both supported by high-quality RCTs):
  • Prednisolone 50-60 mg daily for 5 days, then taper over 5 days, OR
  • Prednisolone 25 mg twice daily for 10 days 1
• Evidence: Two large RCTs (551 and 829 patients) showed 83-94.4% recovery with steroids vs 63.6-81.6% with placebo at 3-9 months 1
• Benefit after 72 hours: Less clear, but may still be considered 1

Second-Line: Consider Adding Antivirals

• May offer oral antivirals in addition to (never instead of) steroids within 72 hours 1
• Dosing options:
  • Valacyclovir 1g three times daily for 7 days, OR
  • Acyclovir 400mg five times daily for 10 days 2
• Rationale: Some smaller trials suggest combination therapy may reduce synkinesis rates (96.5% vs 89.7% full recovery) 1, though evidence is mixed
• Critical caveat: Antivirals alone are ineffective and should never be prescribed as monotherapy 1

Essential Eye Protection (MANDATORY)

• Implement immediately for all patients with impaired eye closure 1
• Prevents corneal injury from exposure keratopathy
• Use artificial tears during day, lubricating ointment at night, eye taping/patching if needed

Pediatric Considerations

• Children have better spontaneous recovery (up to 90%) than adults 2
• No controlled trials support steroid use in children 1
• May consider oral steroids in pediatric patients given similar disease mechanism and favorable benefit-harm ratio, but involve caregivers heavily in decision-making 1

What NOT to Do

• Do NOT obtain routine laboratory testing 1
• Do NOT perform routine diagnostic imaging at initial presentation 1
• Do NOT perform electrodiagnostic testing in incomplete facial paralysis 1
• Do NOT recommend acupuncture, physical therapy, or surgical decompression (insufficient evidence) 1, 3, 4

When to Reassess or Refer

Refer to facial nerve specialist if: 1

1. New or worsening neurologic findings at any point
2. Ocular symptoms developing at any point
3. Incomplete facial recovery at 3 months after onset

Imaging Indications (NOT routine)

Order MRI with gadolinium of entire facial nerve course (including IAC) if: 1, 3

• Atypical features: bilateral palsy, isolated branch involvement, other cranial nerve involvement
• History of trauma or tumor
• No recovery after 3 months
• Worsening paralysis

Common Pitfalls to Avoid

• Missing the 72-hour window: Steroids are most effective when started early—don't delay
• Prescribing antivirals alone: This is ineffective and wastes the critical treatment window 1
• Forgetting eye protection: Corneal injury can cause permanent vision loss
• Over-investigating initially: Bell's palsy is a clinical diagnosis of exclusion; routine labs and imaging add cost without benefit 1
• Assuming all facial weakness is Bell's palsy: Rule out stroke (forehead sparing), Lyme disease, Ramsay Hunt syndrome (vesicles), tumors, and other causes through history and examination 1

Emerging Evidence

Recent meta-analysis suggests high-dose corticosteroids (≥80mg) may be superior to standard doses (40-60mg) with OR 0.17 for nonrecovery at 6 months, though studies had serious risk of bias 5. Japanese guidelines (2023) also strongly recommend systemic standard-dose corticosteroids as the only treatment with robust evidence 6.