Bell Palsy

Clinical Snapshot

Bell palsy is an acute, unilateral, lower motor neuron paralysis of the facial nerve (cranial nerve VII), most often attributed to reactivation of latent herpes simplex virus type 1 within the geniculate ganglion, producing inflammation and edema of the nerve as it passes through the narrow bony facial canal.^[1] Because the nerve is compressed within that fixed bony channel, this swelling is what actually threatens the nerve fibres — the same mechanism that makes early anti-inflammatory treatment time-sensitive. Bell palsy is a diagnosis of exclusion: it must never be presumed until other causes of facial weakness — most urgently stroke, but also Ramsay Hunt syndrome and Lyme disease — have been considered and excluded (see Assessment & Diagnosis).^[2] Most patients recover completely without any specific intervention, but corticosteroid therapy has been shown to reduce the rate of incomplete recovery,^[3] and that benefit is meaningfully greater, and more complete, when treatment is started early — within 72 hours, and ideally within 48 hours, of symptom onset — which makes the timing of this single decision one of the highest-yield counselling points a pharmacist will encounter in this condition.^[4]

Recognize the Condition

Typical presentation

Acute onset (hours to 1-3 days) of unilateral facial weakness or paralysis affecting both the upper and lower face — this is the single most important examination finding in the whole condition, because it is what separates a peripheral facial nerve palsy from a central (stroke) cause. Ask the patient to raise their eyebrows and wrinkle their forehead: preserved forehead movement on the weak side points to a central lesion instead, since the forehead has bilateral cortical innervation and is spared in stroke but not in Bell palsy.

Commonly accompanying features include post-auricular or ear pain (which may precede the facial weakness by a day or two), hyperacusis (increased sensitivity to sound from stapedius muscle weakness), and altered taste over the anterior two-thirds of the tongue (chorda tympani involvement). Decreased tearing, or paradoxically excessive tearing or drooling from poor eyelid and mouth closure, drooping of the mouth corner, and difficulty with speech articulation are also common.

Time course

Weakness typically progresses over hours to a few days and then plateaus. Continued progression beyond 3 weeks, or a very slowly progressive course from the outset, is atypical for Bell palsy and should prompt reconsideration of the diagnosis (see Red Flags & Refer).

Severity determines the treatment track

Mild-to-moderate (incomplete) paralysis

Some voluntary movement is still present in the affected muscles (House-Brackmann grade II-III — see Assessment & Diagnosis). Oral corticosteroid alone is the standard treatment track.

Severe or complete paralysis

No, or almost no, voluntary movement is present in the affected muscles (House-Brackmann grade V-VI). This group — along with immunocompromised patients and suspected Ramsay Hunt syndrome — is where adding an antiviral to the corticosteroid has the best evidence of possible additional benefit (see Choose Initial Treatment).

Risk Factors

Pregnancy, particularly the third trimester and the first few postpartum weeks.^[5]
Hypertension.
Diabetes mellitus.
Recent immunization (e.g., COVID-19 vaccination) has been associated with a modestly increased risk in some studies — vaccine benefits still clearly outweigh this risk, and vaccination should not be withheld or delayed because of it.
A preceding upper respiratory illness, consistent with the proposed viral-reactivation mechanism.
A personal history of a prior episode — recurrence on the same or the opposite side occurs in a minority of patients and should prompt reconsideration of the diagnosis and specialist referral rather than automatic retreatment (see Red Flags & Refer).

Red Flags & Refer

Any of the following should stop you from presuming idiopathic Bell palsy and prompt urgent escalation instead:

Any sign suggesting a central (stroke) cause rather than a peripheral facial nerve palsy — most importantly, forehead-sparing weakness (forehead/eyebrow movement preserved on the weak side), along with limb weakness or numbness, dysarthria out of proportion to facial weakness alone, visual disturbance, ataxia, or any other focal neurological deficit. Manage as a possible stroke with urgent imaging and stroke-protocol activation instead of Bell palsy treatment.
A vesicular rash in the ear canal, on the pinna, or in the oropharynx, suggesting Ramsay Hunt syndrome (herpes zoster oticus) rather than Bell palsy — this changes both the antiviral dosing and the urgency of ENT referral.
Bilateral facial weakness, which is not typical of Bell palsy and instead suggests Guillain-Barre syndrome, Lyme disease, neurosarcoidosis, or granulomatosis with polyangiitis.
Slow, progressive onset over weeks rather than acute onset over hours to a few days — suggests a facial nerve tumour, cerebellopontine angle tumour, or parotid tumour rather than Bell palsy.
Involvement of other cranial nerves — for example, hearing loss or lateral gaze weakness — suggesting a cerebellopontine angle tumour rather than an isolated CN VII palsy.
Systemic features — fever, joint involvement, other-organ symptoms, or a known tick exposure/endemic-area residence — suggesting Lyme disease, neurosarcoidosis, or another systemic illness requiring its own specific workup.
Examination findings of mastoiditis or a parotid mass, which point to a local structural cause rather than idiopathic Bell palsy.
Signs of exposure keratopathy or corneal damage — persistent eye redness, pain, photophobia, foreign-body sensation, or visible corneal clouding — from inadequate eye protection during incomplete eyelid closure. This needs urgent ophthalmology assessment; it is a preventable complication of the facial palsy itself, not a separate diagnosis.
Recurrence of facial palsy, on either side, warrants reconsideration of the diagnosis and specialist referral rather than simply retreating with the standard regimen.

Assessment & Diagnosis

Differential diagnosis of unilateral (and bilateral) facial weakness

Confirm the presentation truly fits idiopathic Bell palsy before treating for it — the table below covers every entity that can present as facial weakness and needs to be actively considered, not just stroke.

Differential diagnosis	Distinguishing findings	Diagnostic steps
Bell palsy (idiopathic)	Acute onset; forehead involved; no other cranial nerve or systemic findings	Clinical diagnosis of exclusion — made only once the entities below have been considered
Stroke (central cause)	Forehead spared (movement preserved); often other neurological deficits — limb weakness, dysarthria, ataxia, visual change	Urgent CT/MRI and stroke-protocol activation
Ramsay Hunt syndrome	Herpes zoster infection; vesicles in the ear canal, on the pinna, or in the oropharynx — can occasionally occur without a visible rash	Clinical diagnosis; PCR/viral testing if the rash is absent but suspicion remains
Facial nerve tumours	Usually painless; slowly progressive rather than acute	Examine for signs of neurofibromatosis; imaging
Cerebellopontine angle tumours	Evidence of CN VI, VIII, or cerebellar deficits — failure of lateral eye deviation, deafness, or limb incoordination on the affected side	Clinical diagnosis; MRI
Parotid tumours	A palpable mass apparent on clinical examination	Clinical examination; imaging
Mastoiditis	Apparent on clinical examination; deafness, ear discharge	Clinical examination
Lyme disease	Skin (erythema migrans) and joint involvement; tick exposure or residence in an endemic area	Serologic testing
Neurosarcoidosis	Variable, depending on which organs are involved	Chest x-ray; further directed workup
Brainstem lesions (e.g., multiple sclerosis)	Other brainstem signs present	MRI
Bilateral facial palsy (a pattern, not a single entity)	Suggests Guillain-Barre syndrome, Lyme disease, neurosarcoidosis, or granulomatosis with polyangiitis rather than Bell palsy	Directed workup per the suspected cause

Rarely, diabetic ischemic cranial neuropathy, HIV infection, and tuberculosis can also cause facial palsy and should be considered when the history supports them.

History

Exact time since symptom onset — the single most time-critical piece of information, since it determines whether the corticosteroid window is still open.
Ear pain, hearing changes, vertigo, and any rash in or around the ear.
Tick exposure, travel to or residence in a Lyme-endemic area, and any erythema migrans-type rash.
Immunocompromising conditions or medications.
Pregnancy status.
Prior episodes of facial palsy.

Examination

Forehead movement — the key test distinguishing a peripheral palsy from a central (stroke) cause.
A full cranial nerve examination and a brief limb/gait assessment to look for any other focal neurological deficit.
Otoscopic examination for vesicles, discharge, or mastoid tenderness.
Palpation of the parotid gland for a mass.
Assessment of eyelid closure — critical for determining eye-protection intensity (see Non-Pharmacologic Treatment).

Grading severity

Objective grading is not required before starting treatment, but it is useful for documenting baseline severity, informing the corticosteroid-plus-antiviral decision, and tracking recovery. The House-Brackmann grading system is the most widely used scale internationally; it is a descriptive, categorical 6-grade classification assigned by clinical judgment, not a point-sum score, so no calculator applies to it.^[6]

Grade	Category	Key features
I	Normal	Normal facial function in all areas; symmetric at rest and with movement.
II	Mild dysfunction	Slight weakness noticeable only on close inspection; complete eye closure achieved with gentle effort.
III	Mild-moderate dysfunction	Obvious but not disfiguring asymmetry; complete eye closure achieved only with full effort.
IV	Moderate dysfunction	Obvious weakness and/or disfiguring asymmetry; incomplete eye closure.
V	Severe dysfunction	Only barely perceptible motion; grossly asymmetric at rest; incomplete eye closure.
VI	Total paralysis	No movement at all; incomplete eye closure with no blink protection.

Grades IV through VI all involve incomplete eye closure — these patients need the most vigilant eye protection (see Non-Pharmacologic Treatment and Pharmacologic Treatment Options).

The Sunnybrook Facial Grading System is a more detailed, continuously-scored alternative used mainly by specialists following patients with an inadequate recovery; it is more sensitive to partial change over time than House-Brackmann but requires more training to administer and is not needed for routine assessment.^[7]

Investigations

Investigations are seldom needed once a complete history and examination have excluded the other causes of facial weakness above — Bell palsy remains a clinical diagnosis, and waiting on results should never delay starting corticosteroid therapy within the effective window.

Electromyography and facial nerve conduction studies can help with prognosis, but only once performed 8-10 days after onset — ordering them earlier does not give useful information.
CT imaging is appropriate when trauma is a plausible cause.
MRI may be indicated when atypical features are present — fever, immunocompromised state, or other focal neurological symptoms or signs.
Lyme serology when the history supports possible exposure — endemic area, tick bite, erythema migrans, joint symptoms.
No routine laboratory testing is otherwise useful.

Treatment Targets

Maximize the probability of complete recovery of facial nerve function by limiting further denervation — achieved primarily through prompt, appropriately-dosed corticosteroid therapy.
Protect the cornea from exposure keratopathy for as long as eyelid closure remains incomplete.
Control pain and inflammation during the acute phase.
Correctly exclude stroke and the other mimics in the differential before committing to a Bell palsy diagnosis and treatment plan.
Identify the specific patients — severe or complete paralysis, immunocompromised, suspected Ramsay Hunt syndrome — who may gain additional benefit from adding an antiviral to the corticosteroid.

Choose Initial Treatment

Direct treatment rule

Confirm the diagnosis first

Complete the history, examination, and differential-diagnosis screen above before starting treatment — do not treat presumptively if any red flag is present (see Red Flags & Refer); a patient having a stroke should never receive Bell palsy treatment instead of a stroke workup.

Corticosteroid timing — the single highest-stakes decision in this condition

Start oral prednisone as soon as possible in every patient with facial paralysis and no contraindication — the greatest benefit is seen when treatment starts within 48 hours of symptom onset, and starting up to 72 hours after onset still provides meaningful benefit. Benefit becomes progressively less certain when started 4-7 days after onset, and there is no good evidence of benefit for corticosteroids started more than 7 days after onset.^[4] Ask the exact date and time of symptom onset at first contact — this single piece of information determines whether the highest-value intervention in this condition is still available.

Corticosteroid regimen

Use oral prednisone — see Pharmacologic Treatment Options and Drug Tables for the exact dose and duration. A short corticosteroid course of 10 days or less does not require a prolonged taper to avoid adrenal suppression, but the standard regimens below include a brief taper based on the largest supporting trial.^[8]

Adding an antiviral

Special situation — severe or complete facial paralysis, immunocompromised status, or suspected Ramsay Hunt syndrome add an antiviral, valacyclovir preferred, to the corticosteroid. Evidence for added benefit from combining an antiviral with a corticosteroid is mixed overall, but the most consistent signal for possible additional benefit is in patients with more severe paralysis at presentation, and the low adverse-effect burden of antivirals makes offering them reasonable in this group even though the benefit is not firmly established.^[9]

Do not use an antiviral alone, without a corticosteroid — antiviral monotherapy has not shown benefit over placebo in the major placebo-controlled trials^[10]^[9] and is not an acceptable substitute for corticosteroid therapy.

Mild-to-moderate (incomplete) paralysis, no immunocompromise, no suspected Ramsay Hunt corticosteroid alone is sufficient — routinely adding an antiviral to every case is not supported by the evidence and adds cost and pill burden without a clear benefit.

Eye protection

Start eye protection immediately in any patient who cannot fully close the affected eye, regardless of paralysis severity or whether a corticosteroid is being used — see Non-Pharmacologic Treatment for the specific regimen. This is not an optional add-on; incomplete eyelid closure creates a real, preventable risk of corneal injury from the moment the palsy starts.

Analgesia

Ibuprofen or acetaminophen for the first 1-2 days is usually sufficient for the pain and edema that can accompany onset; opioids are rarely needed and should prompt reconsideration of the diagnosis if pain is severe or persistent.

Non-Pharmacologic Treatment

Eye protection — essential in every patient with incomplete eyelid closure

Because incomplete or absent voluntary eyelid closure prevents the normal blink reflex from keeping the cornea moist and protected, any patient who cannot fully close the affected eye is at real risk of exposure keratopathy and corneal abrasion — start protection on the day of diagnosis, not after eye symptoms appear.

Lubricate the eye with preservative-free artificial tears or lubricating drops frequently during the day — at least every 1-2 hours while awake if the eye feels dry or irritated, more often if needed.
Apply a thicker lubricating, petrolatum-based ophthalmic ointment at bedtime, then gently tape the eyelid closed overnight — this is the single most effective way to prevent overnight corneal drying, since blinking stops entirely during sleep.
Wear wraparound glasses or goggles during the day to reduce airflow and debris reaching an incompletely-protected eye.
Review taping technique directly with the patient or caregiver — the tape should close the lid without pressing on the globe, and a skin-friendly tape should be used to avoid periocular skin irritation with nightly use.
Continue eye protection until eyelid closure has visibly recovered, not just until the facial weakness subjectively feels better — reassess this specifically at every follow-up.

Facial exercises and physical therapy

Facial muscle exercises, ideally taught and supervised by a physiotherapist, may help recovery when started in the early stages of Bell palsy; overall evidence quality for this intervention is low, but it is a reasonable, low-risk adjunct to offer alongside corticosteroid therapy, not a substitute for it.^[11]

Acupuncture

No high-quality trial evidence establishes a clear benefit for acupuncture in Bell palsy. If a patient wants to pursue it, position it as an adjunct that has not been proven to change outcomes, never as a substitute for timely corticosteroid therapy.

General counselling

Most patients recover completely — reassure the patient early, while being honest that recovery may take weeks to months.
Reinforce that starting corticosteroid treatment as early as possible is the single action within the patient's control most likely to improve the chance of complete recovery.
Counsel specifically on chewing carefully and protecting the mouth from biting the inside of the cheek on the weak side, since sensation and muscle control are both reduced.

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
Prednisone Preferred	1st-line corticosteroid, every patient without a contraindication	60 mg PO once daily for 5 days, then taper over the next 5 days (total 10-day course)	GI upset, hyperglycemia, sodium/fluid retention, hypokalemia, mood changes, insomnia	Start within 72 hours (ideally within 48 hours) of symptom onset — benefit is not established after 7 days. Take with food.
Valacyclovir Special situation	Antiviral adjunct — severe/complete paralysis, immunocompromised, or suspected Ramsay Hunt syndrome	1000 mg PO three times daily for 7 days, together with the corticosteroid course	Headache, nausea	Always given together with a corticosteroid, never alone — antiviral monotherapy has no proven benefit.
Acyclovir Alternative	Alternative antiviral adjunct	400 mg PO five times daily for 10 days, together with the corticosteroid course	Headache, nausea	An alternative to valacyclovir when preferred, or when cost/availability favours it. Same principle applies: always with a corticosteroid, never alone.
Famciclovir Alternative	Alternative antiviral adjunct	500 mg PO three times daily for 7 days, together with the corticosteroid course	Headache, nausea	Not recommended in pregnancy — use valacyclovir or acyclovir instead if an antiviral is needed in that setting.
Ibuprofen Preferred	Analgesia for the first 1-2 days	400 mg PO every 6-8 hours as needed, short course	GI upset; increased GI bleed risk when combined with the corticosteroid course	Usually sufficient alone. Consider acetaminophen first, or a short course only, in patients with other GI risk factors.
Acetaminophen Preferred	Analgesia for the first 1-2 days	500-1000 mg PO every 4-6 hours as needed, short course	Hepatotoxicity at supratherapeutic doses	Preferred when an NSAID is not appropriate, or to combine with ibuprofen for additional relief.
Artificial tears / ocular lubricant drops Preferred	Eye protection, daytime — any patient with incomplete eyelid closure	1-2 drops as needed, up to hourly while awake if needed	Minimal; transient blurring	Preservative-free formulations preferred with this frequency of use. Start the day of diagnosis, not after eye symptoms appear.
Lubricating ophthalmic ointment (petrolatum-based) Preferred	Eye protection, overnight — any patient with incomplete eyelid closure	Small amount to the lower lid at bedtime, then tape the eyelid gently closed	Transient blurring	The single most effective way to prevent overnight corneal drying — do not skip this even if daytime drops feel sufficient.

Not effective alone: antiviral therapy without a corticosteroid has shown no proven benefit over placebo in Bell palsy — never substitute an antiviral for the corticosteroid.^[9]

Special Populations

Pregnancy

Bell palsy occurs more often during pregnancy, most often in the third trimester or the first few postpartum weeks.^[5] Prognosis for recovery is worse in pregnancy than in the general population, for reasons that are not fully established. Supportive care alone is appropriate for most pregnant patients, since most will still recover spontaneously; the decision to use a corticosteroid should be individualized and made with the patient after discussing risks and benefits, since pregnant patients were excluded from the trials establishing corticosteroid benefit. Systemic corticosteroid exposure in the first trimester carries a small increased risk of cleft palate; exposure from the second trimester onward appears substantially safer. If an antiviral is needed, acyclovir or valacyclovir may be used — no signal of harm to fetal development has been found with either. Famciclovir is not recommended in pregnancy because of limited human safety data.

Breastfeeding

Prednisone is considered compatible with breastfeeding — transfer into breast milk is low, and no harm has been reported in exposed infants. Valacyclovir and acyclovir are the preferred antivirals in breastfeeding, given minimal transfer into breast milk and a reassuring reported safety record; data for famciclovir in breastfeeding are limited, so prefer valacyclovir or acyclovir when an antiviral is genuinely needed.

Pediatrics

Current randomized-trial evidence does not demonstrate a benefit from corticosteroid therapy in children with Bell palsy — a large placebo-controlled trial found no improvement in complete recovery with prednisolone compared with placebo.^[12] The risk of incomplete recovery from Bell palsy in children is low regardless of treatment, since the great majority recover fully without any specific therapy. Routine corticosteroid use in children is therefore not currently recommended outside specialist direction; supportive care — eye protection, analgesia as needed, and reassurance — remains the mainstay. There is no evidence available for antiviral use in children with Bell palsy, and it should not be used outside specialist direction.

Renal and hepatic impairment

A short, 10-day corticosteroid course as used for Bell palsy does not require renal dose adjustment. Use caution and closer blood-glucose monitoring in patients with diabetes and in those with hepatic impairment affecting corticosteroid metabolism. The antiviral agents are renally cleared, so acyclovir, valacyclovir, and famciclovir all require dose reduction in significant renal impairment — see each drug's individual Drug Database entry for the specific adjustment.

Other populations requiring caution with corticosteroid therapy

Systemic fungal infection is a contraindication to corticosteroid therapy — do not start prednisone in this setting.
Peptic ulcer disease — use corticosteroids with caution, and avoid adding an NSAID on top of the corticosteroid course when possible.
Poorly controlled diabetes — corticosteroids will worsen glycemic control for the duration of the course; counsel on more frequent blood-glucose monitoring during treatment.
Immunocompromised patients — this group is specifically one where adding an antiviral to the corticosteroid is favoured (see Choose Initial Treatment).

Monitoring & Follow-Up

Arrange follow-up contact within 1-2 weeks of starting treatment to confirm the expected trajectory — most patients begin to show some improvement within the first few weeks, with continued recovery over the following months. Reassess eyelid closure specifically at this visit, since eye-protection intensity should track the actual degree of closure, not the patient's overall sense of improvement. Confirm the full corticosteroid course, and antiviral course if prescribed, was completed as directed. If electromyography or facial nerve conduction studies were ordered for prognosis, remember these are only informative once performed 8-10 days after onset — earlier results should not be used to guide decisions. Watch specifically for delayed complications over the following months: synkinesis (unwanted, linked movements — for example, the eye closing involuntarily during a smile), gustatory lacrimation (tearing while eating, sometimes called crocodile tears), and other signs of aberrant nerve regeneration. Ask about eye symptoms at every contact for as long as eyelid closure remains incomplete, and refer urgently to ophthalmology for any new eye redness, pain, photophobia, or visual change.

Treatment Failure / Next Step

Re-confirm the diagnosis before assuming treatment has failed — re-examine specifically for forehead sparing, other neurological deficits, a vesicular rash that may have appeared after the initial visit, or systemic features pointing to Lyme disease or another alternative diagnosis (see Assessment & Diagnosis).
Confirm the corticosteroid, and antiviral if prescribed, was started within the effective window and the full course was actually completed at the correct dose.
If eyelid closure is still incomplete, escalate eye-protection intensity (more frequent drops, confirm nightly ointment and taping are actually being done) and refer to ophthalmology if there are any signs of corneal irritation or damage.
If there is no meaningful improvement, or the condition is worsening, by about 3 months from onset, refer to otolaryngology or neurology — electromyography/nerve conduction studies (if not already done) and formal facial grading can help with prognosis and further management planning.
Persistent, unwanted synkinetic movements or excessive tearing appearing months after the acute illness are managed with referral for consideration of botulinum toxin injection by a specialist experienced with facial palsy.^[13]
Surgical facial nerve decompression is not a routine treatment-failure step — current evidence is of low quality and insufficient to determine whether it helps or harms, so it remains a specialist-directed option considered only in select, carefully evaluated cases.^[14]

Common Errors to Avoid

Delaying corticosteroid initiation to wait for a specialist referral, imaging, or lab results — treat empirically once red flags have been reasonably excluded, since delay past the 48-72 hour window meaningfully reduces the achievable benefit.
Starting an antiviral without a corticosteroid — antiviral monotherapy has no proven benefit in Bell palsy.
Reflexively adding an antiviral to every case — reserve it for severe/complete paralysis, immunocompromised patients, or suspected Ramsay Hunt syndrome.
Missing forehead sparing or another focal neurological deficit that indicates a central (stroke) cause requiring urgent stroke workup instead of Bell palsy treatment.
Failing to counsel on eye protection — especially nightly ointment and taping — a major, often-overlooked source of preventable harm (exposure keratopathy) in a condition that is otherwise usually self-limited.
Assuming pediatric Bell palsy should be treated the same way as adult Bell palsy — current trial evidence does not support routine corticosteroid use in children.
Restarting or continuing corticosteroids for a presentation now more than 7 days old on the assumption that some treatment is better than none — the evidence does not support benefit in that window, and the adverse-effect burden is not free.
Missing Lyme disease as the actual cause in a patient with a relevant exposure history or endemic-area residence — this needs its own specific antimicrobial treatment, not standard Bell palsy management.
Treating a recurrence exactly like a first episode without reconsidering the diagnosis and involving a specialist.

Clinical Decision Algorithm

Initial assessment — exclude mimics before treating

Acute unilateral facial weakness

Test forehead movement and perform a full cranial nerve and limb/gait exam

Forehead spared, or any other focal neurological deficit

Manage as suspected stroke — urgent imaging and stroke-protocol activation, not Bell palsy treatment

Forehead involved, no other neurological deficit

Screen specifically for a vesicular rash (ear/oropharynx), Lyme exposure, bilateral involvement, slow progressive onset, or a parotid/mastoid finding

Any of these present

Do not treat as idiopathic Bell palsy — work up the specific alternative diagnosis (Ramsay Hunt syndrome, Lyme disease, tumour, etc.)

None present

Idiopathic Bell palsy confirmed — proceed to the adult or pediatric treatment algorithm below

Adult treatment: corticosteroid timing and antiviral decision

Confirmed Bell palsy in an adult — determine time since symptom onset

Within 48-72 hours

Start oral prednisone now — this is the window of greatest benefit

4-7 days since onset

Starting prednisone is still reasonable, but benefit is less certain — discuss this explicitly with the patient

More than 7 days since onset

No good evidence of corticosteroid benefit at this point — continue supportive care and eye protection

If prednisone is being started: assess for severe/complete paralysis, immunocompromise, or suspected Ramsay Hunt syndrome

Any of these present

Add an antiviral (valacyclovir preferred) to the prednisone — never as monotherapy

None present

Prednisone alone is sufficient — do not add an antiviral

In every patient, regardless of the above: start eye protection today if eyelid closure is incomplete — lubricant drops by day, ointment plus taping at night

Pediatric Bell palsy

Child with Bell palsy confirmed (mimics excluded as in Algorithm 1)

Corticosteroids are not routinely recommended — current trial evidence does not show benefit, and spontaneous recovery is very likely regardless

Supportive care: eye protection as needed, analgesia for pain, reassurance, and routine follow-up

Atypical features, incomplete recovery, or diagnostic uncertainty at any point: refer to pediatric neurology or ENT rather than defaulting to adult dosing

Follow-up and treatment failure

Reassess within 1-2 weeks of starting treatment

Improving as expected

Continue supportive care; wean eye protection only as eyelid closure genuinely recovers; routine follow-up to full recovery

No improvement, or worsening

Re-exclude mimics; refer to ENT/neurology; EMG/facial nerve conduction studies (only after 8-10 days) can help with prognosis

Persistent synkinesis, aberrant movement, or excessive tearing months after the acute illness

Refer for consideration of botulinum toxin injection by a specialist experienced with facial palsy

Drug Tables

How to use this table: Doses are adult doses and require patient-specific confirmation (renal/hepatic function, weight, allergy history). Pediatric dosing is weight-based per the current product monograph unless stated. Drug pricing is intentionally omitted. Select any drug name to open its complete Pharmasist Drug Database page.

Antiviral agents are always used together with a corticosteroid in Bell palsy, never alone.

Corticosteroids

The cornerstone of Bell palsy treatment — start as early as possible, ideally within 48 hours and no later than 72 hours of symptom onset.

Drug	Dosage	Adverse effects	Comments
Prednisone	Adults, Option A: 60 mg PO once daily for 5 days, then taper over the next 5 days (total 10-day course) Adults, Option B: 50 mg PO once daily for 10 days, no taper Children: Not routinely recommended — current randomized-trial evidence does not demonstrate benefit in children; use only under specialist direction if considered	GI upset, hyperglycemia, sodium/fluid retention, hypokalemia, hypocalcemia, mood changes, insomnia	Two regimens are both reasonable; either is acceptable. A short course under 2 weeks does not require a prolonged taper to avoid adrenal suppression.

Antivirals (adjunct only — never monotherapy)

Reserve for severe or complete paralysis, immunocompromised patients, or suspected Ramsay Hunt syndrome; always co-prescribed with, never instead of, the corticosteroid course.

Drug	Dosage	Adverse effects	Comments
Valacyclovir	Adults: 1000 mg PO three times daily for 7 days Children: No evidence available for antiviral use in children with Bell palsy — not used outside specialist direction	Headache, nausea	Preferred antiviral adjunct given simpler dosing than acyclovir.
Acyclovir	Adults: 400 mg PO five times daily for 10 days Children: No evidence available for antiviral use in children with Bell palsy — not used outside specialist direction	Headache, nausea	An alternative to valacyclovir when preferred, or when cost/availability favours it.
Famciclovir	Adults: 500 mg PO three times daily for 7 days Children: No evidence available for antiviral use in children with Bell palsy — not used outside specialist direction	Headache, nausea	Not recommended in pregnancy given limited human safety data — use valacyclovir or acyclovir instead in that setting.

Analgesics

For pain and edema, usually only needed for the first 1-2 days.

Drug	Dosage	Adverse effects	Comments
Ibuprofen	Adults: 400 mg PO every 6-8 hours as needed Children: 10 mg/kg PO every 6-8 hours as needed, per product labelling	GI upset; increased GI bleed risk when combined with the corticosteroid course	Prefer a short course; consider acetaminophen first in patients with additional GI risk factors.
Acetaminophen	Adults: 500-1000 mg PO every 4-6 hours as needed Children: 10-15 mg/kg PO every 4-6 hours as needed, per product labelling	Hepatotoxicity at supratherapeutic doses	Preferred when an NSAID is not appropriate.

Eye protection

Essential adjunct in any patient with incomplete eyelid closure — start on the day of diagnosis, not after eye symptoms appear.

Drug	Dosage	Adverse effects	Comments
Artificial tears / ocular lubricant drops	Adults and children: 1-2 drops in the affected eye as needed, up to hourly while awake if needed	Minimal; transient blurring	Preservative-free formulations preferred with frequent daytime use.
Lubricating ophthalmic ointment (petrolatum-based)	Adults and children: Small amount to the lower lid at bedtime	Transient blurring	Apply at bedtime, then gently tape the eyelid closed overnight — the single most effective way to prevent overnight corneal drying.

Other therapies (specialist-directed, later stage)

Not initiated in primary or pharmacy care — included so pharmacists recognize them and can counsel appropriately when a patient is referred for them.

Drug	Dosage	Adverse effects	Comments
OnabotulinumtoxinA (representative botulinum toxin agent)	Adults: Individualized dose and injection sites per specialist protocol	Localized weakness of nearby muscles, bruising	Used for persistent synkinesis or unwanted facial movement appearing months after the acute illness, injected into the specific affected muscles by a specialist experienced with facial palsy. Not for use in the acute phase.

Evidence note: Drug selection, dosing, adverse effects, and comments reflect the AAN 2012 evidence-based guideline update, the AAO-HNSF 2013 clinical practice guideline, and the 2014 Canadian (CMAJ) clinical practice guideline.^[4]^[15]^[2]

References

Bell's palsy: aetiology, clinical features and multidisciplinary care — Journal of Neurology, Neurosurgery & Psychiatry (Eviston TJ, Croxson GR, Kennedy PGE, Hadlock T, Krishnan AV). J Neurol Neurosurg Psychiatry 2015;86(12):1356-1361
Management of Bell palsy: clinical practice guideline — CMAJ, Bell Palsy Working Group of the Canadian Society of Otolaryngology-Head and Neck Surgery (de Almeida JR, Guyatt GH, Sud S, et al). CMAJ 2014;186(12):917-922
Corticosteroids for Bell's palsy (idiopathic facial paralysis) — Cochrane Database of Systematic Reviews (Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Vaidya B, Sullivan F). Cochrane Database Syst Rev 2016;(7):CD001942
Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology — Neurology, American Academy of Neurology (Gronseth GS, Paduga R). Neurology 2012;79(22):2209-2213 (reaffirmed by the AAN 2026-02-21)
Bell's facial nerve palsy in pregnancy: a clinical review — Journal of Obstetrics and Gynaecology (Hussain A, Nduka C, Moth P, Malhotra R). J Obstet Gynaecol 2017;37(4):409-415
Facial nerve grading system — Otolaryngology-Head and Neck Surgery (House JW, Brackmann DE). Otolaryngol Head Neck Surg 1985;93(2):146-147
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