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Why We Treat Bell Palsy With Steroids

March 25, 2017

On the Shoulders of Giants

This rings a Bell
Several studies have shown benefit in treating Bell palsy with steroids and possibly antiviral agents.  This was a meta-analysis of 18 trials, almost 3000 patients, that showed the NNT for one person to avoid unsatisfactory facial recovery was 11 for corticosteroids alone.  And the NNT for the more uncommon effects of synkinesis and autonomic dysfunction was 7.  Antivirals alone were no help, but the combination of steroids and antivirals was synergistic and made corticosteroid treatment even more effective.  The gist is that steroids are the mainstay of Bell palsy treatment and help regardless of the cause.  Since there are numerous causes, and a viral etiology is only one, the addition of antiviral agents is only marginally helpful.  There are different dosing regimens.  Most commonly prednisone 60mg daily x 6 days with a taper to complete 10 days is used; and if added, acyclovir 400mg 5x a day x 10 days, 800mg if varicella is suspected.

Spoon Feed
Corticosteroids are definitely beneficial in Bell palsy.  Antiviral agents are not helpful if used alone but have a mild synergistic effect when added to steroids.  Don’t forget about eye care and protecting the cornea on the affected side from desiccation.  For a great FOAM review of Bell palsy, see emDocs.


JAMA. 2009 Sep 2;302(9):985-93. doi: 10.1001/jama.2009.1243.

Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis.

de Almeida JR1, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, Chen JM.

Author information:

1Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada.

Comment in



New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.


To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy.


The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009.


Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery (> or = 4 months), unsatisfactory short-term recovery (6 weeks to < 4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.


Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P < .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05).


In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.

PMID: 19724046 [PubMed – indexed for MEDLINE]

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