Bell Palsy Organism-Specific Therapy

Updated: Jan 30, 2019
  • Author: Bruce M Lo, MD, MBA, RDMS, FACEP, FAAEM, FACHE, FAAPL, CPE; Chief Editor: Thomas E Herchline, MD  more...
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Specific Organisms and Therapeutic Regimens

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.

Herpes simplex virus (HSV-1 or HSV-2)

See the list below:

  • 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

Varicella-zoster virus (VZV)

See the list below:

  • 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]

Eye care

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.

Special considerations

See the list below:

  • 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]