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About two thirds of cases of acute peripheral facial paralysis are idiopathic and are termed Bell palsy. In a double-blind study from Scotland, patients who were seen within 72 hours after the onset of facial paralysis without an identifiable cause were randomized to one of four 10-day treatments: acyclovir (400 mg 5 times daily) and placebo, prednisolone (25 mg twice daily) and placebo, prednisolone and acyclovir, or double placebo.
Using photos, evaluators who were blinded to treatment group or stage of presentation scored the degree of paralysis according to a well-accepted instrument. Patients were evaluated 3 to 5 days after initiation of treatment and again at 3 and 9 months. Of 752 patients referred for evaluation, 551 were randomized to treatment, and 496 were available for the final evaluation. Patients were divided equally between the sexes, and the mean age was 44.
In the double-placebo group, 65% of patients were fully recovered at 3 months and 85% at 9 months. Prednisolone treatment increased recovery rates significantly to 83% at 3 months and 94% at 9 months. The addition of acyclovir did not yield any improvement over placebo or prednisolone. Adverse events were minor (e.g., dizziness, dyspepsia, nausea).
Editorialists note that, in the U.S., Bell palsy usually is treated with prednisone, and they express no reservation about its substitution for the prednisolone used in this study. They also note that a recent but less robust study showed that vancyclovir (which has greater bioavailability than acyclovir) was effective in patients with more severe paralysis.
Sullivan FM et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med 2007 Oct 18; 357:1598.
Gilden DH and Tyler KL. Bells’s palsy — Is glucocorticoid treatment enough? N Engl J Med 2007 Oct 18; 357:1653.
Comment
This study clears up confusion about the best initial treatment for Bell palsy, showing that low-cost steroids can yield a 9% absolute reduction in risk for residual paralysis. When Bell palsy is diagnosed, the treatment is 1 mg/kg of prednisone or prednisolone daily in two divided doses for 10 days. If steroids are contraindicated, the spontaneous recovery rate of 85% by 9 months is reassuring to both doctor and patient.