Bell’s Palsy and Lyme Disease: Why Steroids May Do More Harm Than Good
Should steroids be used for Bell’s palsy? In typical cases, yes—but when Bell’s palsy is caused by Lyme disease, corticosteroids may increase the risk of long-term nerve damage.
Steroids and Lyme-Related Facial Palsy
A series by Wormser and colleagues examined outcomes in patients with Lyme disease facial palsy who were treated with corticosteroids in addition to antibiotics.
More than half—6 of 11 patients (54.5%)—developed long-term facial nerve dysfunction, persisting an average of 13.1 months after treatment.
Complications included residual facial weakness, synkinesis, facial tightness, hypertonicity, restricted facial movement, and Bogorad’s syndrome (“crocodile tears”).
What Is Synkinesis?
Synkinesis is a complication of facial nerve injury in which nerves regenerate incorrectly, causing involuntary movements during voluntary actions.
Examples include:
- The eye closing while attempting to smile
- Midfacial movement during blinking
- Unpredictable facial muscle contractions
This can interfere with eating, speaking, facial expression, and social interaction.
One review noted that synkinesis may lead to significant functional limitation and social isolation.
Bogorad’s Syndrome (“Crocodile Tears”)
Some patients develop gustatory lacrimation—tearing of the eye while eating.
This condition, also called Bogorad’s syndrome or crocodile tear syndrome, reflects abnormal facial nerve regeneration after injury.
It is another sign of incomplete nerve recovery.
Examples of Long-Term Complications
Patients in the study described tearing while eating, dry eye symptoms, twitching around the eye and forehead, difficulty whistling, jaw discomfort while chewing, facial asymmetry, and intermittent speech difficulty.
One patient ultimately required surgical facial nerve decompression.
Findings in Children
Children are also at risk for long-term complications.
One follow-up study found that 4 out of 11 children (36.4%) with Lyme disease facial palsy developed synkinesis.
This risk is not limited to adults.
Why Steroids May Be Harmful in Lyme Disease
Corticosteroids are standard treatment for idiopathic (typically viral) Bell’s palsy—but Lyme disease is different.
The underlying problem is infection—not inflammation alone.
Suppressing the immune response during active infection may delay bacterial clearance, worsen nerve injury, and increase the risk of long-term neurologic complications.
The duration of antibiotic treatment in the study was relatively short, typically 14–28 days of doxycycline.
The study was not designed to determine whether longer treatment might have altered outcomes.
This highlights the importance of recognizing Lyme disease early when evaluating facial paralysis.
Clinical Takeaway
Steroids may be harmful in patients with Lyme-related Bell’s palsy.
Clinicians should consider Lyme disease in any case of facial paralysis, avoid assuming all Bell’s palsy is viral, evaluate for tick exposure, and recognize that facial nerve complications may persist long after treatment.
Early recognition may help prevent long-term neurologic complications.
Frequently Asked Questions
Can Lyme disease cause Bell’s palsy?
Yes. Lyme disease is a recognized cause of facial nerve paralysis, particularly in endemic regions.
Are steroids safe in Lyme-related Bell’s palsy?
Some studies suggest corticosteroids may worsen long-term facial nerve outcomes in Lyme disease patients.
What is synkinesis?
Synkinesis occurs when facial nerves regenerate incorrectly, causing involuntary facial movements.
What are crocodile tears?
Crocodile tears, or Bogorad’s syndrome, refers to tearing while eating due to abnormal nerve regrowth.
Can children develop long-term complications?
Yes. Children with Lyme-related facial palsy may also develop persistent facial nerve dysfunction.
Related Articles
- Case Report: 46-year-old Canadian man with Bell’s palsy
- Steroid use can lead to long-term treatment failure for Lyme disease patients
- When Lyme disease mimics a heart attack
References
- Wormser GP, McKenna D, Scavarda C, Karmen C. Outcome of facial palsy from Lyme disease in prospectively followed patients who had received corticosteroids. Diagn Microbiol Infect Dis. 2018.
- Husseman J, Mehta RP. Management of synkinesis. Facial Plast Surg. 2008;24(2):242-249.
- McCoy FJ, Goodman RC. The crocodile tear syndrome. Plast Reconstr Surg. 1979;63(1):58-62.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
Does this also apply to other Lyme symptoms
Chronic complications of Lyme disease have been described after steroids.
Hello,
I am a medical student in england. I was in Facial paralysis 1 week ago. Boriella IgM +. I use doxycycline and streoid. What is your suggestion?
I am sorry to hear you are having problems finding the best answer. Doctors in the US tend to prescribe steroids in case the problem is due to a virus. The article I referred to in the Blog describes the consequences of that protocol. I treat my patients clinically. The Bell’s can last awhile. I treat longer if my patient is taking steroids and if there are other symptoms.
My 4 year old is being treated for Lyme and Bell’s Palsy with Doxycycline. Is that enough or should he also be on Prednisone? What else can I do to help the recovery from Bell’s?
Steroids have been helpful for Bell’s palsy due to a virus. It is not clear whether steroids are helpful if the cause Lyme disease. I have been reluctant to use steroids if Lyme disease is the cause.
My 6 year old son has a same kind of symptoms last 2 days, his left side eye since yesterday tearing,hard to close,it doesn’t blink, and his mouth crooked,he doesn’t have any kind of infection except this type of symptoms,I hope your going to make me happy give me right suggestions
That could be Bell’s palsy. You will need to have your son evaluated by a doctor or an ER.
Steroidal therapy can suppress patients’ immune systems, allowing the Borrelia and other co-infections to grow, rather than attacking the infections. You may ask why patients are given steroids like prednisone. The answer is because Lyme is often misdiagnosed as autoimmune diseases, such as fibromyalgia.
I took my daughter to the ER on Friday because she was experiencing facial paralysis (it was a slow progression and she was now on Day 5 of it). They put her on 20 ml of prednisone for 5 days; 15 ml of prednisone for 3 days; and then continuing to wean after that. Her blood work came in today, Monday, and she tested positive for Lymes. I gave her her dose of prednisone tonight but I am worried!! Should I have? She sees a DR tomorrow late afternoon to get on an antibiotic for the Lymes. Should I ask her to get off the prednisone? Can she get off it without being weaned since she is only on day 4 of it? Please advise. Thanks very much.
I have had patients who were started on Prednisone before being diagnosed with Lyme disease. I typically start on an antibiotic if Lyme disease is a consideration. I can’t comment on whether the steroid can be stopped. I am glad to hear your will see a doctor tomorrow.
I got Bell’s palsy about 2 yes ago but never went to the doctor but I still have some symptoms like eye waters when I eat and don’t have full sensitivity on left side of my face I’m wondering if taking ivermectin would help?
I have not seen any studies using ivermectin. You might find my blog helpful. https://danielcameronmd.com/bells-palsy-and-lyme-disease/ or work with neurology/EBT