Bell Palsy Organism-Specific Therapy 

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The most widely accepted treatment for Bell palsy is corticosteroids. ^{[1, 2]} Multiple randomized controlled trials show benefit with the use of corticosteroids. ^{[3, 4, 5, 6, 7, 8]} The revised 2012 guidelines for Bell Palsy issued by the American Academy of Neurology also support the use of corticosteroids and rate them as “highly effective.” ^{[9, 10]}

Antiviral agents have also been studied in this setting and may be used in conjunction with corticosteroids. ^[11] Evidence suggests antivirals have no benefit by themselves. ^{[3, 12, 13, 4, 5, 6]} Two meta-analyses showed conflicting conclusions for the value of combing antiviral agents and corticosteroids. ^{[14, 15]} However, some evidence suggests that a combination of antivirals with corticosteroids is more effective than corticosteroids alone. ^{[16, 17, 18]} If antivirals are used, they should be used in combination with corticosteroids.

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Prednisone 1 mg/kg or 60 mg/day for 6d, followed by a taper, for a total of 10d plus

Acyclovir 400 mg PO 5 times daily for 10d or valacyclovir 500 mg PO BID for 5d

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Prednisone 1 mg/kg or 60 mg/day for 6 d, followed by a taper, for a total of 10 d plus

Acyclovir 800 mg PO 5 times daily for 10d or valacyclovir 1000 mg PO TID for 5d

Caution should be taken when using high-dose valacyclovir in VZV owing to possible adverse effects. Caution should be taken with corticosteroid usage in patients who are pregnant, have an active infection (eg, tuberculosis, sepsis), or are immunocompromised. ^[19]

Impaired eye closure and abnormal tear flow are common with Bell palsy; these leave the eyes at risk for corneal drying and foreign-body exposure.

Manage with tear substitutes, lubricants, and eye protection.

Use artificial tears during waking hours to replace diminished or absent lacrimation.

Lubricants are used during sleep, and they may be used during waking hours if artificial tears cannot provide adequate protection.

Eyeglasses or shields protect the eye from injury and reduce drying by decreasing direct contact of air currents with the exposed cornea.

Eye patches are ineffective, because unopposed third nerve function will result in corneal exposure despite best efforts to approximate eyelid margins.

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The majority of cases will resolve without treatment; patients with severe symptoms are more likely to have residual symptoms.

The potential for benefit is greater if the treatment is started within 72h of symptom onset.

Corticosteroids are rated as “highly effective”.

Antivirals are rated as “possibly effective” only when combined with corticosteroids.

HSV infection is more common than VZV as a cause for Bell palsy.

There is no evidence that surgery is beneficial.

If laboratory studies are positive for Lyme disease or HIV infection, consultation with an infectious disease expert should be considered. ^[19]

Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F, et al. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016 Jul 18. 7:CD001942. [Medline].

Fujiwara T, Haku Y, Miyazaki T, Yoshida A, Sato SI, Tamaki H. High-dose corticosteroids improve the prognosis of Bell’s palsy compared with low-dose corticosteroids: A propensity score analysis. Auris Nasus Larynx. 2018 Jun. 45 (3):465-470. [Medline].

Engström M, Berg T, Stjernquist-Desatnik A, Axelsson S, Pitkäranta A, Hultcrantz M, et al. Prednisolone and valaciclovir in Bell’s palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. Nov 2008. 7(11):993-1000.

Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007 Oct 18. 357(16):1598-607. [Medline].

Axelsson S, Berg T, Jonsson L, Engström M, Kanerva M, Stjernquist-Desatnik A. Bell’s palsy – the effect of prednisolone and/or valaciclovir versus placebo in relation to baseline severity in a randomised controlled trial. Clin Otolaryngol. 2012 Aug. 37(4):283-90. [Medline].

Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell’s palsy: the BELLS study. Health Technol Assess. 2009 Oct. 13(47):iii-iv, ix-xi 1-130. [Medline].

Berg T, Bylund N, Marsk E, Jonsson L, Kanerva M, Hultcrantz M, et al. The effect of prednisolone on sequelae in Bell’s palsy. Arch Otolaryngol Head Neck Surg. 2012 May. 138(5):445-9. [Medline].

Zandian A, Osiro S, Hudson R, Ali IM, Matusz P, Tubbs SR, et al. The neurologist’s dilemma: a comprehensive clinical review of Bell’s palsy, with emphasis on current management trends. Med Sci Monit. 2014 Jan 20. 20:83-90. [Medline]. [Full Text].

Gronseth GS, Paduga R,. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012 Nov 27. 79(22):2209-13. [Medline].

Schwartz SR, Jones SL, Getchius TS, Gronseth GS. Reconciling the clinical practice guidelines on Bell’s palsy from the AAO-HNSF and the AAN. Neurology. 2014 May 27. 82(21):1927-9. [Medline].

Kim HJ, Kim SH, Jung J, Kim SS, Byun JY, Park MS, et al. Comparison of acyclovir and famciclovir for the treatment of Bell’s palsy. Eur Arch Otorhinolaryngol. 2016 Oct. 273 (10):3083-90. [Medline].

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 Apr 10. 56(7):830-6. [Medline].

Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7. CD001869. [Medline].

Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis. BMJ. 2009 Sep 7. 339:b3354. [Medline]. [Full Text].

de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009 Sep 2. 302(9):985-93. [Medline].

Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K, et al. Valacyclovir and prednisolone treatment for Bell’s palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol. 2007 Apr. 28(3):408-13. [Medline].

Lee HY, Byun JY, Park MS, Yeo SG. Steroid-antiviral treatment improves the recovery rate in patients with severe Bell’s palsy. Am J Med. 2013 Apr. 126(4):336-41. [Medline].

Shahidullah M, Haque A, Islam MR, Rizvi AN, Sultana N, Mia BA. Comparative study between combination of famciclovir and prednisolone with prednisolone alone in acute Bell’s palsy. Mymensingh Med J. 2011 Oct. 20(4):605-13. [Medline].

Taylor DC, Khoromi S, Zachariah SB. Bell Palsy. Medscape Reference. Available at http://emedicine.medscape.com/article/1146903-overview.. Accessed: May 12, 2013.

Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Bell Palsy Organism-Specific Therapy 

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