Bell’s palsy – antivirals and steroids for all?
Reviewed by Christopher Burgess

The role of antiviral medications in the treatment of Bell’s palsy remains somewhat controversial. Antivirals alone do not appear to be helpful, whereas numerous studies have shown that corticosteroids improve the chance of a full recovery compared to placebo. What has been less clear is whether a combination of steroids and antiviral medications improves recovery compared to steroids alone. A randomised controlled trial published in The New England Journal of Medicine (NEJM) in 2007 suggests that there is no difference in recovery rate from a Bell’s palsy with steroids and aciclovir versus steroids alone. Other studies do however suggest that antivirals can augment the benefits of steroids. ENT UK guidance from 2022 attempts to resolve this conundrum by recommending that antivirals are added to steroids for patients with a severe facial palsy (House-Brackmann V-VI), whilst steroids alone are recommended for milder facial palsies. Further studies have been published since this guidance was issued. This paper is a systematic review of studies conducted up until August 2023 looking at recovery rates from Bell’s palsy with steroids alone versus steroids plus antivirals. Ten RCTs enrolling 2893 participants were included in the meta-analysis. Rates of complete recovery (H-B I-II) were assessed for each intervention. The overall data showed that recovery was 88.7% in the steroid plus antiviral group, versus 83.2% in the steroid only group. This difference was statistically significant (RR 1.09, 95% CI 1.03-1.15). The authors conclude that steroids plus antivirals may improve the cure rate for Bell’s palsy relative to steroids only. As is often the case, the significant heterogeneity and potential for bias in the included studies lead the authors to call for additional RCTs with high-quality methodologies and larger sample sizes. Nevertheless, the low side-effect profile of antivirals in general coupled with the overall results of this meta-analysis would certainly suggest that clinicians should give consideration to administering antivirals as well as steroids to all patients diagnosed with Bell’s palsy in the absence of a clear contraindication. 

Comparison of glucocorticoids with antiviral drugs versus glucocorticoids alone in the management of Bell’s Palsy: A systematic review and meta-analysis of randomized clinical trials.
Zhu Y, Liang T, Liu S, et al.
AM J OTOLARYNGOL
2025;46(1):104583.