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Am Fam Physician. 2009;80(11):1304-1306

Background: Treating Bell palsy (idiopathic facial paralysis) remains problematic because an optimal therapy has not been established. Corticosteroids are the most widely accepted treatment; however, antivirals are also often used because herpes simplex virus (HSV) has been isolated from the facial nerve endoneurial fluid of some affected patients. There are conflicting reports whether combining antivirals with corticosteroids is more effective than monotherapy. Goudakos and Markou attempted to clarify which treatment option would provide the best results.

The Study: The authors conducted a meta-analysis of randomized controlled trials examining clinical outcomes with Bell palsy. All studies compared corticosteroid therapy versus combined corticosteroid and antiviral treatment, with at least three months of follow-up. Studies were excluded if they included patients with uncontrolled diabetes mellitus, peptic ulcer disease, suppurative otitis media, herpes zoster, multiple sclerosis, pregnancy, or systemic infection. The primary outcome was complete recovery of facial motor function three months after starting therapy.

Results: The authors reviewed five studies that included a total of 738 patients. All studies used prednisolone or deflazacort (not available in the United States) as the corticosteroid, and acyclovir (Zovirax) or valacyclovir (Valtrex) as the antiviral agent. Meta-analysis of available data showed no difference at three months in complete recovery rates between the corticosteroid group and the combined therapy group (odds ratio [OR] = 1.03, P = .88). No difference in recovery occurred between valacyclovir and acyclovir. Individual study data also showed no difference between the corticosteroid group and the combined therapy group in complete recovery at four, six, or nine months after initiating treatment. Initiating treatment within three days (versus seven days) of disease onset did not affect recovery rates. Adverse effect rates were also similar between treatment groups.

Conclusion: Adding an antiviral agent to corticosteroids for treating Bell palsy does not result in better recovery rates of facial motor function. The authors state that these findings do not justify the addition of an antiviral in this situation, but that further trials are needed to more confidently assess the potential value of antiviral medications in the treatment of Bell palsy.

editor's note: With true (i.e., idiopathic) Bell palsy, there is no reason to believe that antivirals might improve symptoms. The real question is whether they might be useful for the roughly one third of patients thought to have Bell palsy whose symptoms are attributed to HSV, or varicella-zoster virus (VZV) without cutaneous lesions (zoster sin herpete).1,2 This meta-analysis did not separately examine this subgroup. However, its findings are in line with other studies35 that found no added benefit of antivirals in the larger Bell palsy population, despite the large presumed included subgroup of HSV- or VZV-affected patients. One study specifically examining this subgroup also reported no benefit of adding valacyclovir to a corticosteroid.2 Regardless of whether HSV or VZV may underlie a Bell palsy case, the evidence favors corticosteroid monotherapy for treatment.

A Cochrane Review also showed no definitive benefit of adding antivirals to corticosteroids for Ramsay Hunt syndrome (herpes zoster oticus),6 which presents with similar facial paralysis and zoster lesions in or around the ear canal. However, these findings relied on one small, low-quality study. At least for Ramsay Hunt syndrome, many physicians may be more comfortable using combination therapy until further evidence is available.—k.t.m.

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