What is the recommended dosing of Valtrex (valacyclovir) for the treatment of Bell's palsy?

Valacyclovir Dosing for Bell's Palsy

For Bell's palsy, valacyclovir should be dosed at 1,000 mg three times daily for 7 days, always in combination with oral corticosteroids and initiated within 72 hours of symptom onset. 1, 2

Treatment Recommendations

First-line Treatment

• Oral corticosteroids are the primary treatment for Bell's palsy with strong evidence supporting their use 3, 4
• Prednisone regimen: 50-60 mg daily for 5 days followed by a 5-day taper 1

Antiviral Therapy

• Valacyclovir should never be used as monotherapy for Bell's palsy (strong recommendation against) 3
• Valacyclovir may be offered as an adjunct to oral steroids within 72 hours of symptom onset 3
• Dosing: 1,000 mg three times daily for 7 days 1, 2
• Alternative: Acyclovir 400 mg five times daily for 10 days 1

Evidence Analysis

The American Academy of Otolaryngology-Head and Neck Surgery guidelines clearly state that antiviral monotherapy should not be prescribed for Bell's palsy 3. However, they do indicate that combination therapy with an oral antiviral plus steroids may be offered within 72 hours of symptom onset 3.

A 2023 rapid evidence review in American Family Physician confirms that valacyclovir (1 g three times daily for 7 days) combined with corticosteroids may reduce rates of synkinesis (involuntary co-contraction of facial muscles) 1.

The strongest evidence supporting combination therapy comes from a multicenter, randomized, placebo-controlled study by Hato et al. (2007), which found that valacyclovir plus prednisolone resulted in significantly better recovery rates (96.5%) compared to prednisolone alone (89.7%) 2. This benefit was particularly pronounced in patients with complete or severe palsy.

Important Clinical Considerations

• Timing is critical: Treatment should be initiated within 72 hours of symptom onset 3
• Patient selection: The benefit of combination therapy may be greatest in patients with severe facial paralysis 2
• Contraindications: Consider patient-specific factors such as diabetes, pregnancy, or previous steroid intolerance 3
• Monitoring: Patients should be reevaluated if they develop new or worsening neurologic findings or have incomplete recovery after 3 months 4

Common Pitfalls to Avoid

1. Using antiviral therapy alone - This is ineffective and not recommended 3, 1
2. Delaying treatment - Benefits diminish when treatment is initiated after 72 hours 3
3. Neglecting eye protection - Patients with incomplete eye closure require measures to prevent corneal damage 4
4. Overlooking severe cases - Patients with complete paralysis may benefit most from combination therapy 2

While some studies show modest or no additional benefit from adding valacyclovir to steroid therapy 5, 6, the most recent evidence and guidelines support the option of combination therapy, particularly for patients with severe palsy.