#4 Bell’s Palsy: What to Do and What Not to Do?
CLINICAL QUESTION
Do corticosteroids or antivirals provide any benefit to patients with Bell’s palsy?
BOTTOM LINE
The best evidence indicates that corticosteroids (in doses of prednisolone 25 mg BID or 60 mg x5 days, then tapered by 10 mg/day) improve the odds of complete recovery from Bell’s palsy. Trials of antivirals (used either alone or in addition to prednisolone) are inconsistent, but they seem to offer little to no advantage.
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EVIDENCE
Corticosteroids:
- Cochrane review1 of seven Randomized Controlled Trials (RCTs) including 895 patients comparing corticosteroids to placebo or no treatment.
- Satisfactory recovery at >6 months: Corticosteroids 83% versus no corticosteroid 72%, Number Needed to Treat (NNT)=10.
- Meta-analysis2 of 10 RCTs including 2,419 patients comparing addition of antivirals (+/- corticosteroids) to placebo or no antiviral.
- No statistically significant difference in complete recovery: Antivirals 70.6%, no antiviral 68.7%.
- No benefit in severe Bell’s palsy and in patients also receiving corticosteroids.
- Satisfactory recovery: Antivirals 79.5% versus no antiviral 74.6%, NNT=21
- Results not statistically significant when excluding trials at high risk of bias.
- No statistically significant difference in complete recovery: Antivirals 70.6%, no antiviral 68.7%.
- Cochrane review3 of 10 RCTs of 2,280 patients found that adding antivirals to corticosteroids increased likelihood of complete recovery, but:
- Inappropriately included “satisfactory but incomplete recovery” (House-Brackmann grade 2) as complete recovery.
- Limitations: Only one RCT at low risk of bias, efficacy exaggerated in smaller, lower-quality studies; selective outcome reporting.
- Other meta-analyses found similar conclusions for corticosteroid efficacy4 and antiviral inefficacy.5
- Consistent with results of two highest-quality trials.6,7
- Canadian Bell’s palsy guidelines8 recommend:
- Corticosteroids for all patients with Bell’s palsy.
- Against using antivirals alone, or adding to corticosteroids for mild-moderate Bell’s palsy.
- Considering adding antivirals to corticosteroids for severe Bell’s palsy (based on older meta-analysis4).
- Corticosteroid doses in two high-quality trials:
- Prednisolone 25 mg BID x10 days.6
- Prednisolone 60 mg/day x5 days, then tapered by 10 mg/day.7
- Dose of prednisone = prednisolone.
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This evidence confirms my practice. I do not prescribe antivirals for Bell’s palsy.