Lyme Disease Facial Paralysis Treatment(Lyme Neuroborreliosis)
Expert diagnosis, medical management, and advanced facial reanimation for tick-borne nerve damage.
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What is Lyme Disease-Associated Paralysis?
Lyme disease is an infection caused by the bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected blacklegged (deer) ticks. When the infection spreads to the nervous system—a condition known as Lyme neuroborreliosis—it frequently targets the cranial nerves.
The facial nerve (7th cranial nerve) is the most commonly affected nerve in Lyme disease. The resulting inflammation and swelling of the nerve within its narrow bony canal causes sudden facial weakness or complete paralysis, typically occurring days or weeks after the initial tick bite.
In endemic regions, Lyme disease is one of the leading causes of acute facial paralysis, yet it is frequently misdiagnosed as Bell's palsy due to their similar presentation.
Information supported by the Mass Eye and Ear and American Academy of Family Physicians.
A tick bite can lead to systemic bacterial infection, targeting the facial nerve and causing acute weakness.
The Danger of Misdiagnosis: Lyme vs. Bell's Palsy
Differentiating between Lyme-associated facial palsy and idiopathic Bell's palsy is critical because the treatments are fundamentally different.
Bell's palsy is treated with high-dose corticosteroids. Lyme-associated palsy is treated with antibiotics. Dr. Jowett's 2017 Laryngoscope study found that giving steroids for Lyme-associated facial palsy is associated with worse long-term facial outcomes. If you have facial paralysis and have recently been in a tick-endemic area — or have fever, joint pain, fatigue, headache, or neck stiffness — tell your doctor before starting steroids so Lyme testing and antibiotics can be started.
Dr. Jowett co-authored FACE DROPS, a published clinical risk tool that helps clinicians separate Lyme-associated palsy from Bell's palsy at the bedside. In a Lyme-endemic area during Lyme season, testing is warranted for any acute facial palsy regardless of score.
Lyme Disease Facial Paralysis Symptoms
While the facial droop may look identical to Bell's palsy, Lyme-associated paralysis is often accompanied by a broader set of systemic symptoms.
Unilateral or Bilateral Paralysis
The face will lose muscle tone, making it difficult to smile or speak. Notably, Lyme disease is one of the very few conditions that can cause bilateral facial paralysis (paralysis on both sides of the face simultaneously or sequentially).
Systemic "Flu-Like" Symptoms
Before or alongside the paralysis, patients frequently experience profound fatigue, severe headache, neck stiffness, fever, joint pain, and generalized muscle aches (arthralgia/myalgia).
The Erythema Migrans Rash
Some patients will develop the classic "bullseye" rash associated with Lyme disease. However, it is crucial to note that many patients who develop neurologic Lyme symptoms never saw a tick or a rash.
Lyme Disease Facial Paralysis Treatment Options
Early intervention drastically improves outcomes. Most patients fully recover facial function with prompt medical care, but specialized treatment is available for those with chronic, incomplete recovery.
Antibiotic therapy is central to treatment of confirmed acute Lyme disease and should be directed by the clinician managing the infection.
- Oral Antibiotics: A prolonged course of oral doxycycline is highly effective for most patients.
- Intravenous (IV) Antibiotics: May be required if there is evidence of broader central nervous system involvement, such as meningitis.
- Eye Care: When eyelid closure is incomplete, frequent lubricating drops, ointment, and nighttime closure as directed are essential to protect the cornea. Eye pain, light sensitivity, or a vision change requires urgent ophthalmic assessment.
What the Evidence Shows
Lyme facial palsy is treated as an infection first. Steroids alone can be the wrong first move.
- IDSA, AAN, and ACR guidelines recommend 14–21 days of antibiotics for Lyme cranial neuropathy.
- Bilateral weakness, fever, joint pain, or a tick-endemic stay raise concern for Lyme, not Bell's palsy.
- If the diagnosis is still uncertain in the first 72 hours, steroids may be started and then individualized once Lyme testing returns.
- Dr. Jowett's FACE DROPS work was built to tell these look-alikes apart at the bedside.
- Blood antibody testing is the recommended first step rather than routine PCR or culture. Antibodies can take three to four weeks to appear, so a test drawn very early may be negative even when Lyme is the cause.
- Spinal fluid testing is not needed for most people with isolated facial palsy. It is reserved for signs of brain or spinal-cord involvement, and CT or MRI generally adds little when the palsy is the only finding.
- Antibiotics are recommended for everyone with Lyme-associated facial palsy, including people whose face is already improving. Oral and intravenous regimens performed comparably in studies, so oral doxycycline is often the simplest choice.
- Guidelines make no recommendation for or against adding steroids to antibiotics in confirmed Lyme facial palsy. One prospective study found neither benefit nor harm, and other work raises the possibility of poorer long-term facial outcomes, so the decision is individualized.
- Recovery from the infection itself is generally excellent, but the face does not always follow. Research suggests roughly half of people may be left with some lasting change such as synkinesis, tightness, or asymmetry.
Why Choose Revitalis for Lyme Facial Paralysis?
Dr. Nate Jowett is a facial nerve surgeon whose clinical and peer-reviewed work includes facial reanimation. His fellowship training and background span facial plastic surgery, engineering, and reconstructive microsurgery.
Whether you are days into a diagnosis or have lived with incomplete recovery for years, Dr. Jowett offers the full spectrum of care, from medical management to cutting-edge surgical reconstruction, to help you regain your smile and confidence.
Common questions
Questions Patients Ask
Can Lyme facial palsy occur without a bull's-eye rash?
Yes. Erythema migrans is helpful when present, but it may be absent, unnoticed, or already resolved. Exposure, systemic symptoms, local epidemiology, examination, and testing are considered together.
Is a spinal tap always needed?
No. Lumbar puncture is not routine for every isolated facial palsy. It may be useful when meningitis, painful radiculitis, other neurologic findings, or an alternative diagnosis is suspected.
What if facial tightness remains after the infection is treated?
Persistent tightness and linked movements can reflect synkinesis after the nerve heals. Neuromuscular retraining, selective botulinum toxin, and occasionally surgery can improve function; additional antibiotics do not treat established synkinesis.
My Lyme test was negative. Could it still be Lyme?
It can be, especially very early. Blood antibody testing is the recommended first step, but antibodies can take three to four weeks to appear, so a test drawn in the first days may be negative even when Lyme is the cause. Exposure history, season, and whether both sides are weak all inform the decision to retest.
Do I still need antibiotics if my face is already improving?
Yes. Antibiotics treat the underlying infection rather than the facial weakness itself, and they are recommended in all confirmed cases regardless of how the face is trending. Oral and intravenous regimens performed comparably in studies, so oral doxycycline is often the simplest choice.
Should I take steroids along with the antibiotics?
This is genuinely uncertain. Guidelines make no recommendation for or against adding steroids in confirmed Lyme facial palsy. One prospective study found neither benefit nor harm, and other work raises the possibility of poorer long-term facial outcomes, so the decision is individualized with your clinician.
How likely am I to be left with lasting facial changes?
Recovery from the infection itself is generally excellent, but the face does not always follow. Research suggests roughly half of people may be left with some lasting change such as synkinesis, tightness, or asymmetry. Facial retraining, botulinum toxin, and in selected cases surgery can improve those symptoms.
Answers are general and individualized at consultation.
Medical References & Evidence-Based Guidelines
- FACE DROPS: A Clinical Risk Assessment Tool for Differentiation of Acute Lyme Disease-Associated Facial Palsy From Bell Palsy. McEntire CRS, Chung SY, Chang B, Barrera KJ, Zhao Y, Joseph JW, Wormser GP, Jowett N, Chwalisz BK. Neurol Clin Pract. 2025 Jun; 15(3):e200476. PMID: 40290705.
- Steroid Use in Lyme Disease-Associated Facial Palsy Is Associated with Worse Long-Term Outcomes. Jowett N, Gaudin RA, Banks CA, Hadlock TA. Laryngoscope. 2017 Jun; 127(6):1451-1458. PMID: 27598389.
- Clinical Practice Guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology: 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Neurology. 2021;96(6):262-273. PMID: 33257476.
- Adjunctive Corticosteroids for Lyme Neuroborreliosis Peripheral Facial Palsy-a Prospective Study With Historical Controls. Avellan S, Bremell D. Clin Infect Dis. 2021;73(7):1211-1215. PMID: 33905494.
- Differentiating Bell's Palsy From Lyme-Related Facial Palsy. Guez-Barber D, Swami SK, Harrison JB, McGuire JL. Pediatrics. 2022;149(6):e2021053992. PMID: 35586981.
- A General Approach to Facial Palsy. Jowett N. A General Approach to Facial Palsy. Otolaryngol Clin North Am. 2018 Dec; 51(6):1019-1031. PMID: 30119926.
- A Contemporary Approach to Facial Reanimation. Jowett N, Hadlock TA. JAMA Facial Plast Surg. 2015 Jul-Aug; 17(4):293-300. PMID: 26042960.
- Clinical and epidemiological features of Lyme neuroborreliosis in adults and factors associated with polyradiculitis, facial palsy and encephalitis or myelitis. Radzišauskienė D, Urbonienė J, Jasionis A, et al. Sci Rep. 2023;13(1):19881. PMID: 37964035.
- Approach to Facial Weakness. Wang Y, Cruz CD, Stern BJ. Semin Neurol. 2021;41(6):673-685. PMID: 34826871.
- Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review. Moncaliano MC, Ding P, Goshe JM, et al. J Plast Reconstr Aesthet Surg. 2023;87:361-368. PMID: 37931512.