Forget about antivirals for Bell’s palsy

3 Feb


A guy comes in with a facial droop. You check for eyebrow raise and unequal smile and correctly identify this as a isolated peripheral VIIth nerve palsy. (Nice job not bothering the stoke fellow)


1) Eye protection
-patch to close at night and put some lacrilube in there. Artificial tears Q1 hour during the day

2) Antivirals?

minimal extra efficacy when added to steroids vs. steroids alone, not statistically significant (looked at both valacyclovir and acyclovir)

-treating with antivirals alone was significantly worse than treating with steroid alone, and no better than placebo. (BMC Neuro 2011)

-consider adding antivirals in severe patients (only barely perceptible motion of face or complete paralysis)
3) Steroids
Prednisolone (60 mg daily for five days, then tapered by 10 mg daily, for a total treatment length of 10 days) was studied in a large RCT.
-Patients treated with prednisolone in this RCT had a shorter return to recovery vs. those without steroid treatment.(Lancet 2008).
-An easy substitute would be Prednisone 60mg PO daily for 1 week.

–(whole) facial droop/paralysis, check eyebrows (upper face) & smile (lower face); if both involved, think 7th nerve/Bell’s palsy
eye protection/lube/tears
–antivirals not too useful, consider in severe palsy

steroids hasten recovery; 7-10 day course prednisone.

Submitted by R. Morris.

Reference(s): Numthavaj, P. BMC Neurology 2011;  Prednisolone and valaciclovir in Bell’s palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. 2008 Nov;7(11):993-1000. Epub 2008 Oct 10; image

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