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Abstract

We found that treatment with steroids and antiviral agents was more effective than steroids alone in treating severe to complete Bell's palsy. This type of combination therapy is not novel, with many researchers mentioning its advantages.1Hato N. Murakami S. Gyo K. Steroid and antiviral treatment for Bell's palsy.Lancet. 2008; 371: 1818-1820Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar In contrast, recent guidelines documented that steroid-antiviral combination therapy shows only a modest increase in recovery compared with steroids alone and recommended that clinicians explain to patients the limited effects of additional antiviral treatment. In addition, a recent multicenter study from Finland reported that, while prednisolone is always effective irrespective of the grade of facial palsy, the addition of valacyclovir did not increase the recovery rate at 12 months.2Axelsson S. Berg T. Jonsson L. Engström M. Kanerva M. Stjernquist-Desatnik A. Bell's palsy—the effect of prednisolone and/or valaciclovir versus placebo in relation to baseline severity in a randomised controlled trial.Clin Otolaryngol. 2012; 37: 283-290Crossref PubMed Scopus (37) Google Scholar Because prednisolone is believed to be effective in treating Bell's palsy, a double-blinded study in which one group is not treated with steroids may be unethical. Furthermore, the total of 77 patients with severe facial palsy who were prescribed prednisolone with or without valaciclovir may not be sufficiently large to confirm the effect of combination therapy. It also is important to remember that zoster sine herpete is frequently associated with Bell's palsy. Varicellar zoster virus, which is considered more virulent than herpes simplex virus, is present in about 8%-28% of patients with Bell's palsy.1Hato N. Murakami S. Gyo K. Steroid and antiviral treatment for Bell's palsy.Lancet. 2008; 371: 1818-1820Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Moreover, Bell's palsy patients classified as having zoster sine herpete showed better recovery when treated with combinations of steroids and antiviral agents than when treated with steroids alone, with some of these patients showing early deterioration or late onset of recovery.3Lee H.Y. Kim M.G. Park D.C. et al.Zoster sine herpete causing facial palsy.Am J Otolaryngol. 2012; 33: 565-571Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Early deterioration, between 11 and 17 days, has been observed in 28% of patients with Bell's palsy and was a negative prognostic factor for complete recovery after 12 months.4Marsk E. Hammarstedt L. Berg T. et al.Early deterioration in Bell's palsy: prognosis and effect of prednisolone.Otol Neurotol. 2010; 31: 1503-1507PubMed Google Scholar Our findings suggest that early deterioration in Bell's palsy may indicate the presence of zoster sine herpete.3Lee H.Y. Kim M.G. Park D.C. et al.Zoster sine herpete causing facial palsy.Am J Otolaryngol. 2012; 33: 565-571Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The combination of prednisolone (120-200 mg/d) plus valacyclovir (1000 mg/d for 5 days) has been recommended in the treatment of patients with severe Bell's palsy. Patients with a reddish auricle or eardrum, severe otalgia, or taste dysfunction should receive an increased dose of valacyclovir (3000 mg/d), due to the possibility of zoster sine herpete.5Murakami S. Diagnosis and treatment of facial nerve paralysis.Nihon Jibiinkoka Gakkai Kaiho. 2012; 115: 118-121Crossref PubMed Scopus (2) Google Scholar Thus, our experience suggests that patients with severe Bell's palsy should be treated with a combination of a steroid and an antiviral agent in agreement with the views of De Ru and Van der Veen. Antivirals and their dosages should be optimized and individualized in the treatment of these patients. Combination Therapy for Bell's PalsyThe American Journal of MedicineVol. 126Issue 12PreviewTreatment of Bell's palsy with antivirals constitutes an ongoing discussion. Lee et al1 were the first to perform a study in the relevant population domain (ie, patients with a severe palsy). Their manuscript confirms the results of a previous retrospective study.2 The authors are to be congratulated with the outcome: they offer clear proof of the effectiveness of combination therapy—corticosteroids and antivirals—enhancing recovery in patients with a severe palsy. Full-Text PDF