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Bell Palsy — Steroids, Acyclovir, Both, or Neither?

Prednisolone increased the odds of complete recovery at 3 months and 9 months, whereas acyclovir appeared to offer no benefit.

Patients with Bell palsy often receive corticosteroids and antiviral drugs directed against Herpes simplex, a presumed cause in some cases. Because the evidence supporting these treatments is modest, researchers in Scotland mounted this study, which included more patients than the total number in recent meta-analyses.

In a double-blind, placebo-controlled trial, 551 patients with Bell palsy (mean age, 44) were randomized to receive a 10-day course of prednisolone (25 mg, twice daily), acyclovir (400 mg, 5 times daily), both drugs, or double placebo. At 3 months, complete recovery was noted in 83% of patients who received prednisolone and 64% of patients who did not — a significant difference. At 9 months, these proportions were 94% and 82%, respectively — still significantly favoring prednisolone. However, acyclovir was ineffective, both in comparison with nonuse of acyclovir and as add-on therapy with prednisolone.

Comment: Although most patients with Bell palsy recover fully without treatment, steroid therapy enhances recovery in some patients and should be offered unless there are contraindications. In contrast, acyclovir appears to be ineffective. Editorialists discuss another recent trial in which valacyclovir plus prednisolone was slightly better than prednisolone plus placebo (Otol Neurotol 2007; 28:408). This outcome is perhaps explained by the greater bioavailability of valacyclovir (compared with acyclovir). Thus, the editorialists believe that valacyclovir "could still be considered" in patients whose facial palsy is severe or complete — the subgroup in which most benefit was noted.

— Allan S. Brett, MD

Published in Journal Watch General Medicine October 17, 2007

Citation(s):

Sullivan FM. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med 2007 Oct 18; 357:1598.

• Original article (Subscription may be required)
• Medline abstract (Free)

DH and Tyler KL. Bell’s palsy — Is glucocorticoid treatment enough? N Engl J Med 2007 Oct 18; 357:1653.

• Original article (Subscription may be required)
• Medline abstract (Free)