Can Lyme Disease Cause Bell’s Palsy or Facial Palsy?
A sudden facial droop may be called Bell’s palsy
In Lyme-endemic regions, facial palsy may point to Lyme disease
Early recognition can change evaluation and treatment
Can Lyme disease cause Bell’s palsy? Yes. Lyme disease is an important cause of facial palsy in both children and adults living in or visiting Lyme-endemic regions. A person who suddenly develops facial weakness, facial droop, or difficulty closing one eye may initially be diagnosed with Bell’s palsy, but Lyme disease should also be considered.
Facial palsy is often diagnosed as Bell’s palsy. However, in Lyme-endemic regions, Lyme disease is a well-recognized cause of facial nerve palsy.
Researchers and clinicians often use the term facial palsy or facial nerve palsy because these terms describe weakness of the facial nerve regardless of cause.
Patients and families, however, commonly hear the term Bell’s palsy. Bell’s palsy traditionally refers to facial paralysis without a clearly identified cause, while Lyme disease facial palsy has an identifiable infectious cause.
Mislabeling Lyme-related facial palsy as Bell’s palsy can delay appropriate evaluation and treatment.
This article is part of the Pediatric Lyme Disease guide, which explores how Lyme disease may present differently in children.
What Facial Nerve Palsy Looks Like
Facial nerve palsy occurs when the seventh cranial nerve is affected, leading to weakness of the facial muscles.
Symptoms may include:
- Drooping on one side of the face
- Difficulty closing one eye
- Asymmetry when smiling
- Drooling
- Changes in speech articulation
- Facial weakness or facial paralysis
Symptoms often appear suddenly but may be subtle at first.
Parents may initially notice incomplete eye closure or a slight asymmetry in a child’s smile.
Although most cases are unilateral, bilateral facial palsy—while uncommon—can occur in Lyme disease.
Facial palsy may be the only obvious manifestation of early disseminated Lyme disease. Some patients never develop a recognized rash and do not remember a tick bite.
Bell’s Palsy vs Lyme Disease Facial Palsy
Bell’s palsy refers to facial paralysis without a clearly identified cause.
In everyday practice, however, the term is often used broadly for any sudden facial weakness. In Lyme-endemic regions, facial palsy may actually represent Lyme disease affecting the facial nerve.
Lyme disease should be considered before labeling a case as idiopathic, especially during tick season or when headache, fever, neck stiffness, rash, joint pain, or other symptoms suggest possible Lyme disease.
For broader neurologic involvement, see Neurologic Lyme Disease.
What the Research Shows
A retrospective study published in Pediatrics evaluated 306 children presenting with acute facial palsy in a Lyme-endemic region.
- 68% were diagnosed with Bell’s palsy
- 27% had Lyme-related facial palsy
- A small number had other causes
More than 1 in 4 cases were Lyme-related.
Children with Lyme-related facial palsy were more likely to present between June and November and to have preceding symptoms such as fever, malaise, headache, muscle pain, or joint pain.
Many did not recall a tick bite and did not have a rash.
Can Lyme Disease Cause Facial Paralysis?
Yes. Lyme disease can affect the facial nerve and cause facial weakness, facial droop, or facial paralysis.
Facial palsy may occur with or without other obvious Lyme disease symptoms.
Some patients have a known tick bite or rash, while others do not remember either.
This is one reason facial palsy in Lyme-endemic areas deserves careful evaluation.
Facial Palsy in Children: Why Lyme Disease Can Be Missed
Children with facial palsy are often labeled as having Bell’s palsy, particularly when facial weakness appears suddenly.
However, Lyme disease facial palsy in children is common in endemic regions and may occur even without a rash or known tick bite.
Recognizing pediatric Lyme disease early may help avoid delayed diagnosis and unnecessary testing.
Evaluation of Facial Palsy
When a child or adult presents with facial weakness, clinicians consider multiple possible causes.
In isolated facial palsy:
- Neuroimaging often does not add diagnostic value.
- Lumbar puncture is not routinely necessary.
- In Lyme-endemic regions, Lyme disease should be considered, particularly during tick season or when headache, fever, rash, neck stiffness, or other Lyme symptoms are present.
- Lyme antibody testing may support the diagnosis, although early Lyme disease can occasionally produce false-negative results.
Additional testing may be reserved for patients with other neurologic findings or atypical features.
See the Lyme Disease Symptoms Guide for a broader symptom overview.
Recovery and Prognosis
Most patients recover from facial palsy, whether due to Bell’s palsy or Lyme disease.
In the pediatric study, nearly all patients with follow-up regained normal facial strength.
The role of corticosteroids remains uncertain when facial palsy is caused by Lyme disease. Corticosteroids are commonly recommended for idiopathic Bell’s palsy when started early. However, observational studies have raised concern that steroid use in Lyme disease-associated facial palsy may be associated with less complete long-term recovery. Other studies have reported mixed findings, and no randomized clinical trials have definitively established whether corticosteroids improve or worsen outcomes in Lyme disease-associated facial palsy. Because treatment recommendations differ, clinicians in Lyme-endemic areas should consider Lyme disease before assuming facial palsy is idiopathic Bell’s palsy or prescribing corticosteroids alone.
Patients who cannot fully close the affected eye may require lubricating eye drops, lubricating ointment, or temporary eye protection to help prevent corneal injury while the facial nerve recovers.
When Lyme disease is suspected, timely evaluation and appropriate antibiotic treatment are important.
Frequently Asked Questions
Can Lyme disease cause Bell’s palsy?
Yes. Lyme disease can affect the facial nerve and cause facial palsy that may be mistaken for Bell’s palsy.
What is the difference between Bell’s palsy and Lyme facial palsy?
Bell’s palsy is facial paralysis without a clearly identified cause. Lyme facial palsy occurs when Lyme disease affects the facial nerve.
Can Lyme disease cause facial droop?
Yes. Facial droop, difficulty closing one eye, and an uneven smile may occur when Lyme disease affects the facial nerve.
Does Lyme facial palsy occur without a rash?
Yes. Some patients with Lyme-related facial palsy do not recall a tick bite and never notice a rash.
Is facial palsy from Lyme disease permanent?
Many patients recover facial strength, especially when Lyme disease is recognized and treated appropriately.
Clinical Takeaway
Facial palsy should not automatically be labeled as Bell’s palsy, especially in Lyme-endemic areas.
Sudden facial droop, facial weakness, or difficulty closing one eye may warrant evaluation for Lyme disease, even without a known tick bite or rash.
Recognizing Lyme disease facial palsy early may help prevent delayed diagnosis and guide appropriate antibiotic treatment.
Related Articles
These related articles explore neurologic Lyme disease, diagnostic challenges, and other conditions that may mimic or accompany Lyme disease facial palsy.
Autonomic Dysfunction in Lyme Disease
Delayed Lyme Disease Diagnosis
Lyme Disease Misdiagnosis
Lyme Carditis
Lyme Coinfections
References
- Guez-Barber D, et al. Differentiating Bell’s palsy from Lyme-related facial palsy. Pediatrics. 2022.
- Jowett N, Gaudin RA, Banks CA, et al. Steroid use in Lyme disease-associated facial palsy is associated with worse long-term outcomes. Laryngoscope. 2017;127(6):1451-1458.
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
