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Health condition · Clinically reviewed

Bell's palsy, early steroid, eye protection and specialist facial palsy care.

Sudden one-sided facial weakness is frightening, and the first 72 hours matter. A clear plan improves recovery and protects the eye.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE CKS, AAO-HNS 2013 and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including early prednisolone, eye protection and specialist facial palsy MDT pathways.

Key facts

Bell's palsy at a glance.

The essentials, in plain English: what it is, how common it is, and how it is treated in the UK today.

  • What it is

    An acute, idiopathic lower motor neurone weakness of the facial nerve, affecting one side of the face and peaking within 72 hours.

  • How common

    Around 20 to 30 cases per 100,000 people each year in the UK, the most common cause of acute facial paralysis.

  • Likely cause

    Reactivation of herpes simplex virus type 1 in the geniculate ganglion is the leading hypothesis, causing nerve inflammation and swelling.

  • Who is at risk

    Pregnancy, diabetes, hypertension, obesity and immunocompromise all raise the risk.

  • Foundation therapy

    Prednisolone within 72 hours of onset significantly improves recovery. Eye protection is critical from day one.

  • Prognosis

    About 70 percent recover fully without treatment, rising to around 85 percent with early steroid, usually within 3 to 6 months.

Why this guide matters

The first 72 hours change the outcome.

Bell's palsy is common, treatable and usually recovers. The three points below shape everything else on this page.

  • Rule out stroke first

    A forehead that still wrinkles on the weak side points to an upper motor neurone cause. Treat as suspected stroke and call 999.

  • Start prednisolone within 72 hours

    Early steroid improves the chance of full recovery from around 70 percent to 85 percent, backed by Cochrane evidence.

  • Protect the eye from day one

    Lubricants, ointment, taping and moisture chambers prevent corneal damage while the eye cannot close.

How the diagnosis is made

From first droop to a clear plan.

The steps a UK GP, ED clinician or neurologist will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    Clinical history

    Sudden unilateral weakness peaking within 72 hours, often preceded by retroauricular pain, altered taste or hyperacusis.

  2. 02

    Assessing

    Rule out upper motor neurone

    Forehead sparing points to a stroke, not Bell's palsy. A full facial exam including the forehead is essential.

  3. 03

    Assessing

    House-Brackmann grading

    Severity is graded I to VI, from normal function to total paralysis. Grade guides prognosis and management.

  4. 04

    Confirming

    Ear and mouth exam

    Otoscopy to look for vesicles or a red tympanic membrane suggesting Ramsay Hunt. Check for parotid masses.

  5. 05

    Confirming

    Targeted bloods and swabs

    Consider Lyme serology after tick exposure, HIV, VZV PCR if vesicles, ACE and chest X-ray if sarcoid suspected.

  6. 06

    Escalating

    Imaging when atypical

    MRI with gadolinium if bilateral, progressive, persisting beyond 2 months or if a tumour is suspected. Ultrasound if a parotid mass is felt.

  7. 07

    Escalating

    ENT and audiology

    Audiometry if hearing loss, and ENT review for recurrent or unusual presentations, or when facial reanimation may be needed.

Typical timeline: most people are diagnosed and started on treatment at the first visit.

Symptoms

What Bell's palsy actually looks like.

Sudden one-sided facial weakness, often with ear pain, altered taste and hyperacusis, and the red flag features that must not be missed.

  • Sudden unilateral weakness

    Onset over hours to days, peaking within 72 hours. One side of the face droops and feels heavy.

  • Inability to close the eye

    The eye on the affected side may not shut fully, leaving the cornea exposed and at risk of drying.

  • Drooping mouth and drooling

    The corner of the mouth pulls down. Food and saliva may collect on the weak side.

  • Loss of forehead wrinkling

    The forehead on the affected side does not crease when raising the eyebrows, a lower motor neurone sign.

  • Altered taste and hyperacusis

    Reduced taste over the front two thirds of the tongue and heightened sensitivity to sound in the affected ear.

  • Retroauricular pain

    Pain behind the ear often precedes or accompanies the weakness by a day or two.

  • Speech and eating changes

    Slurred speech, difficulty pursing lips and trouble drinking from a straw are common early complaints.

  • Red flag - forehead sparing

    If the forehead moves normally, this is an upper motor neurone lesion. Treat as a suspected stroke and call 999.

Treatment

How Bell's palsy is treated in the UK.

Early prednisolone and eye protection form the backbone. Physiotherapy, botulinum toxin and reanimation surgery help when recovery is incomplete.

  • Prednisolone (early steroid)

    Prednisolone 60 mg once daily for 10 days, or 25 mg twice daily for 10 days, started within 72 hours of onset.

  • Antivirals in severe disease

    Aciclovir, valaciclovir or famciclovir added to steroid may benefit severe cases (House-Brackmann IV to VI). Marginal and not routinely recommended.

  • Eye protection

    Lubricating drops by day, ointment and taped closure at night, plus a moisture chamber. Urgent ophthalmology if exposure keratitis develops.

  • Facial physiotherapy

    Neuromuscular retraining and biofeedback support recovery and reduce the risk of synkinesis when weakness persists.

  • Botulinum toxin

    Used for temporary lagophthalmos (upper lid weighting) and later for synkinesis on the affected or overactive contralateral side.

  • Oculoplastic surgery

    Gold or platinum lid weights, tarsorrhaphy or brow lift protect the eye and improve symmetry when medical measures are not enough.

  • Facial reanimation surgery

    Masseter-to-facial nerve transfer, gracilis free flap or fascia lata sling can restore smile and tone in long-standing paralysis.

  • Specialist MDT referral

    Facial Palsy UK-affiliated centres including Queen Victoria, Oxford, Sheffield and Cambridge lead complex reanimation care.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or neurologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE CKS. Bell's palsy.

  • AAO-HNS. Clinical Practice Guideline: Bell's Palsy (2013).

  • Cochrane. Corticosteroids for Bell's palsy.

  • Facial Palsy UK. Patient information and specialist centre guidance.

Red flags

When facial weakness needs urgent attention.

Most Bell's palsy settles with early steroid and eye care. These are the situations that need something more.

  • Forehead sparing

    An upper motor neurone pattern suggests stroke. Treat as a medical emergency and call 999 for FAST assessment.

  • Bilateral facial weakness

    Bilateral palsy is rarely Bell's. Think Guillain-Barre, Lyme disease, sarcoidosis or HIV, and refer for urgent workup.

  • Gradual onset beyond 72 hours

    Slowly progressive weakness raises suspicion of tumour, including acoustic neuroma or parotid malignancy, and needs MRI.

  • Vesicles in the ear or palate

    Ramsay Hunt syndrome (VZV reactivation) needs prompt antivirals and steroid, and specialist ENT input.

  • Other cranial nerve signs

    Additional neurological deficits point away from an isolated facial nerve lesion. Refer for urgent neurology assessment.

  • Parotid mass or lymphadenopathy

    A palpable mass changes the picture entirely. Urgent imaging and head and neck referral are needed.

  • Exposure keratitis

    Red, painful or blurred eye needs same-day ophthalmology review to prevent corneal ulceration and scarring.

  • No recovery at 3 months

    Persistent House-Brackmann V or VI at 3 months warrants MRI, electrodiagnostic tests and facial palsy MDT referral.

  • Recurrent episodes

    Recurrent or alternating palsy needs workup for Melkersson-Rosenthal syndrome, sarcoidosis, Lyme and tumour.

Living with it

A recoverable condition, with the right support.

Four things that make the biggest difference day to day: eye care, patience, guided physiotherapy and honest support for the emotional side.

A quiet reminder

Recovery is measured in months, not days.

Progress can feel slow at first. Small daily habits, kept up for months, do far more than a heroic week.

  1. 01 Eye

    Protect the eye every day

    Drops through the day, ointment and gentle taped closure at night. A single missed night can cause a corneal abrasion.

  2. 02 Patience

    Expect 3 to 6 months

    Most people recover well within 3 to 6 months. Progress is often slow and stepwise rather than dramatic.

  3. 03 Movement

    Gentle, guided exercises

    Facial retraining with a specialist physiotherapist beats generic exercises. Overworking weak muscles can cause synkinesis.

  4. 04 Mind

    Ask for support early

    Facial change affects confidence, work and relationships. Psychological support is a normal part of recovery, not a last resort.

Frequently asked

Everything we get asked about Bell's palsy.

Quick answers on steroid, antivirals, eye protection and specialist facial palsy care.

  • What is Bell's palsy?

    It is a sudden, one-sided weakness or paralysis of the face caused by inflammation of the facial nerve. It is idiopathic, meaning no single cause is found, though reactivation of herpes simplex virus type 1 is the leading theory.

  • How is it different from a stroke?

    Bell's palsy affects the whole side of the face including the forehead, because it is a lower motor neurone lesion. A stroke usually spares the forehead. Any facial weakness with forehead sparing, arm weakness or slurred speech must be treated as a stroke and needs a 999 call.

  • Do I need steroids?

    Yes if you are seen within 72 hours of onset and have no contraindications. Prednisolone 60 mg once daily for 10 days significantly improves the chance of full recovery, based on Cochrane evidence and NICE CKS guidance.

  • Should I take antivirals as well?

    For most people the added benefit is marginal. Antivirals such as aciclovir or valaciclovir may be added in severe cases (House-Brackmann IV to VI) or when Ramsay Hunt is suspected, but routine use is not recommended by all guidelines.

  • How do I protect my eye?

    Use lubricating drops during the day, ointment at night, and tape the eye closed before sleep. Wear glasses or moisture chamber goggles outdoors. Seek same-day ophthalmology review for any red or painful eye.

  • What if I do not recover fully?

    A specialist facial palsy team can help with botulinum toxin for synkinesis, oculoplastic procedures for the eye, and reanimation surgery such as nerve transfer or gracilis free flap. UK centres include Queen Victoria, Oxford, Sheffield and Cambridge.

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