What is the treatment for Bell's palsy related to herpes zoster (shingles)?

From the Guidelines

Bell's palsy related to shingles, also known as Ramsay Hunt syndrome, requires prompt treatment with antiviral medications and corticosteroids, and the standard treatment includes valacyclovir (1000 mg three times daily) or acyclovir (800 mg five times daily) for 7-10 days, combined with prednisone (60-80 mg daily, tapered over 10-14 days). Treatment should begin within 72 hours of symptom onset for best results, as supported by high-quality randomized controlled trials with a preponderance of benefit over harm 1. Pain management is also important, using medications like acetaminophen, NSAIDs, or in severe cases, gabapentin or pregabalin for nerve pain. Some key points to consider in the treatment of Bell's palsy related to shingles include:

• Protecting the affected eye if it cannot close properly by using artificial tears during the day and lubricating ointment at night, possibly with an eye patch.
• Physical therapy may help maintain muscle tone and prevent contractures.
• Most patients see improvement within a few weeks, though complete recovery may take months.
• Seeking immediate medical attention is crucial, as early treatment significantly improves outcomes by reducing inflammation of the facial nerve and limiting viral replication. It is also important to note that antiviral monotherapy should not be used alone for patients with new-onset Bell’s palsy, as it has been shown to be no better than placebo with regard to facial nerve recovery 1. However, combination antiviral therapy may be offered in addition to oral steroids within 72 hours of symptom onset for patients with Bell’s palsy, as it has been shown to have some benefit in randomized controlled trials with minor limitations and observational studies with equilibrium of benefit and harm 1. In pediatric patients, the use of oral steroids is less clear, but may be considered given the presumed similar disease process of Bell’s palsy in adults and children, as well as the generally favorable benefit-harm ratio of steroid therapy 1.

From the FDA Drug Label

The recommended dosage of VALTREX for treatment of herpes zoster is 1 gram 3 times daily for 7 days Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash.

The treatment for bells related to shingles (herpes zoster) is 1 gram of valacyclovir three times daily for 7 days. Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash 2.

• Key points:
  • Dosage: 1 gram three times daily
  • Duration: 7 days
  • Initiation: at the earliest sign or symptom
  • Timing: within 48 hours of rash onset
  • Drug: valacyclovir 2

From the Research

Treatment Options for Bell's Palsy Related to Shingles

• The treatment for Bell's palsy, which may be related to shingles, typically involves corticosteroids and antiviral medications 3, 4, 5, 6.
• Corticosteroids, such as prednisolone, are the mainstay of treatment and should be initiated within 72 hours of symptom onset 3, 6.
• Antiviral therapy, such as valacyclovir, may be used in combination with corticosteroids, but its effectiveness is still debated 7, 4, 6.
• A study found that valacyclovir and prednisolone therapy was more effective in treating Bell's palsy than conventional prednisolone therapy 4.
• Another study found that prednisolone shortened the time to complete recovery in patients with Bell's palsy, whereas valaciclovir did not affect facial recovery 6.

Management and Care

• Management of Bell's palsy includes eye care, botulinum toxin type A injection, physiotherapy, surgery, and acupuncture, although the evidence for these treatments is limited 5.
• Psychological and emotional care is also important, as facial disability caused by facial nerve paralysis can result in anxiety and stress 5.
• A thorough history and physical examination are essential for establishing the correct diagnosis and choosing the correct treatment options 3.

Prognosis and Recovery

• The presence of pain at Days 11 to 17 after symptom onset may indicate a worse prognosis for facial recovery 7.
• The overall rate of patient recovery from Bell's palsy can be high, with one study finding a recovery rate of 96.5% with valacyclovir and prednisolone therapy 4.
• The time to complete recovery can be shortened with prednisolone treatment, but the effectiveness of antiviral therapy is still unclear 6.