Bell's palsy (use of steroid therapy)

• a systematic review of four randomised controlled trials by Williamson and Whelan (BJGP, 1996) has revealed that (compared with placebo) steroid therapy improves the complete facial recovery rate in patients with Bell's palsy (1)
• two systematic reviews concluded that Bell's palsy could be effectively treated with corticosteroids in the first seven days, providing up to a further 17% of patients with a good outcome in addition to the 80% that spontaneously improve (2,3)

Key points (4):

• facial palsy improves after treatment with oral prednisolone:
  
  
  • for people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone
    • no consensus regarding the optimum dosing regimen, but options include (1):
      • prednislone 25 mg twice daily for 10 days, or
      • prednisolone 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred
        
        
  • around a fifth of patients will progress from partial palsy, so these patients should also be treated
  • no supportive evidence has been found for use of steroids or antivirals in children with Bell's palsy
    
    
• with respect to combined oral antiviral therapy and prednisolone in adults this review stated
  • "...there is support for the use of oral prednisolone with aciclovir in patients presenting with moderate to severe facial palsy, ideally within 72 hours.."
  • however more recent studies (5,6) have not shown benefit for antiviral therapy in combination with prednisolone in this condition
    
    
• treatment of partial Bell's palsy is controversial; a few patients don't recover if left untreated
  
  
• treatment is probably more effective before 72 hours and less effective after seven days
  
  
• inabilty to close the eye on the affected side, can lead to irritation and corneal ulceration
  • requires urgent consultation with an ophthalmologist

Reference:

• (1) NICE CKS (Accessed 31/3/23). Bell's Palsy.
• (2) Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56: 830-6.
• (3) Ramsey MJ, DerSimonian R, Holtel MR, Burgess LP. Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis. Laryngoscope 2000;110: 335-41
• (4) Holland NJ, Weiner GM. Recent developments in Bell's palsy.BMJ. 2004 Sep 4;329(7465):553-7
• (5) Sullivan FM, et al. Early treatment with prednisolone or acyclovir in Bell's palsy.N Engl J Med 2007;357:1598
• (6) Engstrom M et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. 2008 Nov;7(11):993-1000.