Cochrane for Clinicians

Putting Evidence into Practice

Antiviral Therapy for Bell Palsy


Am Fam Physician. 2016 May 1;93(9):742-743.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are antivirals effective therapy for Bell palsy?

Evidence-Based Answer

The combination of antiviral agents and corticosteroids is more effective than corticosteroids alone for the complete recovery of patients with Bell palsy (number needed to treat [NNT] = 15) and for the resolution of motor synkinesis and excessive tear production (NNT = 12). (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Antivirals should not be used alone to treat Bell palsy. (SOR: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

Untreated idiopathic facial paralysis, or Bell palsy, leaves up to 30% of patients with some level of permanent facial asymmetry or pain.1 Previous meta-analyses have demonstrated the effectiveness of corticosteroids at reducing the rate of long-term disability.2 Some evidence suggests that recurrent viral infections, including herpes simplex virus and varicella zoster virus, are common causes of Bell palsy. This review evaluated the effectiveness of antiviral agents alone or in combination with corticosteroids for the treatment of Bell palsy. An earlier version of this review, which included two low-quality studies judged to be at high risk of bias, concluded that the combination of antivirals and corticosteroids was no more effective than corticosteroids alone for the treatment of Bell palsy.3

This Cochrane review included 10 trials with a total of 2,280 participants. The authors used meta-analysis to compare several treatment regimens and a variety of outcomes. Complete recovery rates of facial nerve function in patients with Bell palsy were improved by treatment with corticosteroids plus antivirals vs. corticosteroids alone at six months (relative risk [RR] = 0.61; 95% confidence interval [CI], 0.39 to 0.97; NNT = 15 [95% CI, 10 to 200]; n = 1,315). A subgroup analysis of patients with severe Bell palsy (i.e., House-Brackmann index of 5 or 6 out of 6) found that more patients

Author disclosure: No relevant financial affiliations.


Gagyor I, Madhok VB, Daly F, et al. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2015;( 11): CD001869.

The practice recommendations in this activity are available at

editor's note: The numbers needed to treat reported in this Cochrane for Clinicians were calculated by the AFP medical editors based on raw data provided in the original Cochrane review.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. government, the Department of the Army, or the Department of Defense.


show all references

1. Peitersen E. The natural history of Bell's palsy. Am J Otol. 1982;4(2):107–111....

2. Salinas RA, Alvarez G, Daly F, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2010;(3):CD001942.

3. Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009;(4):CD001869.

4. Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis [published correction appears in BMJ. 2013;346:f151]. BMJ. 2009;339:b3354.

5. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell's Palsy executive summary. Otolaryngol Head Neck Surg. 2013;149(5):656–663.

6. Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012;79(22):2209–2213.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



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