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Early Treatment of Bell Palsy

Early treatment with steroids, but not with acyclovir, improved patients’ chances for full recovery.

Bell palsy (BP) resolves in most cases, but up to 30% of sufferers have prolonged facial paralysis and pain. Although steroids and antivirals — alone or in combination — are commonly used for treatment, their effectiveness remains unclear. Investigators in Scotland now report results from a double-blind trial examining the efficacy of steroids and acyclovir in the early treatment of BP. Adults presenting during the first 72 hours of symptoms were randomized to receive prednisolone (50 mg/day), acyclovir (2 g/day), both, or placebo, for 10 days. The primary outcome measure was recovery of facial-nerve function at 3 and 9 months, as determined using the House–Brackmann scale.

Of the 551 patients randomized, 496 had outcome measures assessed. At both time points, complete-recovery rates were significantly higher among participants randomized to prednisolone than among those randomized to no prednisolone (83% vs. 64% at 3 months, 94% vs. 82% at 9 months; P<0.001 for both comparisons). In contrast, complete-recovery rates were similar between participants randomized to acyclovir and those randomized to no acyclovir (85% vs. 91% at 9 months; P=0.1). Acyclovir provided no additional benefit when combined with prednisolone. At 9 months, prednisolone use was associated with a 12% absolute risk reduction; the number needed to treat to achieve one additional complete recovery was eight (95% confidence interval, 6–14).

Comment: This study provides convincing evidence that steroids, given early in the course of BP, increase the likelihood of complete recovery during the first 9 months, whereas acyclovir provides no benefit. As editorialists point out, these findings apply only to the tested antiviral, acyclovir. Other, better-absorbed antivirals — such as valacyclovir — deserve further study before all antivirals are completely abandoned for BP treatment.

— Daniel J. Diekema, MD, MS

Published in Journal Watch Infectious Diseases October 17, 2007

Citation(s):

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

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• Medline abstract (Free)

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

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• Medline abstract (Free)