Steroids harmful to patients with Bell’s palsy caused by Lyme disease

Steroids and Bell’s Palsy: 54% Had Lyme Complications

A case series by Wormser and colleagues, published in the journal Diagnostic Microbiology and Infectious Disease, examines the success of treatment after long-term follow-up with eleven patients. All of the patients with Lyme disease facial palsy (LDFP) received corticosteroids in addition to antibiotics.

The authors found that 6 of the 11 patients (54.5%) suffered from facial nerve dysfunction an average of 13.1 months following the onset of treatment with corticosteroids. Dysfunction was defined as having residual facial muscle weakness, synkinesis, facial tightness and discomfort, facial muscle hypertonicity, restriction of facial movements, and gustatory epiphoria (Bogorad’s syndrome).

Understanding Synkinesis and Bogorad’s Syndrome

Synkinesis is a complication of facial paralysis. “Patients experience hypertonic contractures and synkinetic movements such as eye closure with volitional movement of the mouth or midfacial movement during volitional or reflexive eye closure,” Husseman explains in the journal Facial Plastic Surgery.

“Synkinesis can cause functional limitation with activities such as eating, drinking, smiling, and may even lead to social isolation.”

Some patients with Bell’s palsy suffer from Bogorad’s syndrome, also known as gustatory lacrimation or “crocodile tear syndrome.” Patients with this condition will have tearing of the eye while eating.

Long-Term Complications in Patients Treated with Steroids

The 6 patients who continued to have facial nerve dysfunction included:

• 52-year-old man with “tearing of left eye when eating (Bogorad’s syndrome); mild residual weakness left side”
• 51-year-old man with “mild residual left sided weakness; dryness left eye; after speaking a lot, left sided facial muscles feel abnormal”
• 56-year-old man with “narrowed palpebral fissure right eye; dry mouth; sensation of muscles around right eye being squeezed; tearing of right eye; twitching of the area between the eyes on the forehead; new dimple right cheek; intermittent lisp”
• 25-year-old man with “narrowed palpebral fissure left eye; reduced forehead movement; right sided jaw discomfort with eating; tearing of the left eye when eating (Bogorad’s syndrome)”
• 61-year-old man with “narrowed palpebral fissure right eye; difficulty whistling; right eye discharge at night”
• 70-year-old woman who had “surgical facial nerve decompression nearly 3 months after onset of the LDFP”

Children can also present with long-term complications from facial palsy caused by Lyme disease. On follow-up, one study found 4 out of 11 children (36.4%) with LDFP who had residual facial nerve dysfunction had synkinesis, explains Wormser.

Treatment Duration and Study Findings

The duration of antibiotic treatment was short. Patients were typically prescribed 14-28 days of doxycycline. Two children were treated with an oral beta-lactam antibiotic.

The study was not designed to determine whether additional antibiotics would have been helpful. The study raises concerns for those suffering from facial palsy triggered by Lyme disease who are treated with corticosteroids.

“The principal finding in this study is that a high proportion of corticosteroid-treated patients suffered sequelae when evaluated at approximately 1 year of follow-up,” writes Wormser. “Although corticosteroids are frequently prescribed for LDFP,” he writes, “the efficacy of this therapy has not been established.”

Frequently Asked Questions

Are steroids safe for Bell’s palsy caused by Lyme disease?

No. This study found that 54.5% of patients treated with corticosteroids developed long-term facial nerve dysfunction, including synkinesis and persistent weakness. While steroids may help viral Bell’s palsy, their efficacy for Lyme-related facial palsy has not been established and may be harmful.

What is synkinesis and how does it affect patients?

Synkinesis is involuntary facial muscle movement that occurs when trying to make a different expression—for example, the eye closing when trying to smile. It can cause functional limitations with eating, drinking, and smiling, and may lead to social isolation.

What is Bogorad’s syndrome?

Bogorad’s syndrome, also called “crocodile tear syndrome,” causes tearing of the eye while eating. It’s a complication of facial nerve damage where nerve signals get crossed, triggering tear production during chewing or eating.

How long did complications last in this study?

Facial nerve dysfunction persisted an average of 13.1 months after treatment with corticosteroids. Some patients required surgical intervention, and many experienced ongoing symptoms affecting daily activities and quality of life.

Should children with Lyme-related Bell’s palsy receive steroids?

This study found that 36.4% of children with Lyme-induced facial palsy developed synkinesis after steroid treatment. Given the lack of proven benefit and risk of long-term complications, steroids should be avoided until Lyme disease is ruled out through testing.

Clinical Takeaway

This study documents a concerning pattern: more than half of patients with Lyme-related facial palsy who received corticosteroids developed long-term complications lasting over a year. The complications—synkinesis, persistent weakness, Bogorad’s syndrome—are not minor inconveniences. They affect eating, drinking, facial expression, and social engagement. Some patients required surgical intervention.

The critical message for clinicians: steroids are frequently prescribed for Bell’s palsy, but when the cause is Lyme disease, they may do more harm than good. Before reaching for prednisone, test for Lyme disease—particularly in endemic areas or when there’s any history suggesting tick exposure. The 14-28 day antibiotic courses in this study may also have been inadequate for some patients, raising questions about optimal treatment duration when steroids complicate the clinical picture.