Is acyclovir (antiviral medication) recommended for treatment of Bell's palsy of 1 week duration?

Acyclovir is Not Recommended for Bell's Palsy at 1 Week Duration

Acyclovir alone is not recommended for Bell's palsy treatment, and at 1 week duration, even combination therapy with steroids is no longer indicated as the 72-hour treatment window has passed. 1, 2

Treatment Recommendations Based on Timing

• Oral corticosteroids are the first-line treatment for Bell's palsy but are only effective when initiated within 72 hours of symptom onset 1, 2
• The recommended steroid regimen is prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 3
• Antiviral therapy alone (including acyclovir) should NOT be prescribed for Bell's palsy as it is ineffective 1, 3, 4
• Combination therapy with antivirals plus steroids is only considered within the 72-hour window, not at 1 week duration 2, 3

Evidence Against Acyclovir Monotherapy

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that antiviral monotherapy should not be prescribed for Bell's palsy 1, 3
• A landmark study published in NEJM showed no benefit of acyclovir alone at 3 months (71.2% recovery with acyclovir vs. 75.7% without acyclovir) 5
• At 9 months, recovery rates were 85.4% for acyclovir vs. 90.8% for no acyclovir, suggesting no benefit 5

Management Approach for 1-Week Duration Bell's Palsy

• Focus on eye protection if the patient has impaired eye closure to prevent corneal damage 2, 3

  • Implement lubricating ophthalmic drops for daytime protection 1
  • Use ophthalmic ointments for nighttime protection 1
  • Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 1

• Monitor for recovery and refer if:

  • New or worsening neurologic findings develop 1, 2
  • Ocular symptoms develop 1, 2
  • Incomplete facial recovery persists 3 months after initial symptom onset 1, 2, 3

Natural Course and Prognosis

• Approximately 70% of Bell's palsy patients with complete paralysis recover facial function completely within 6 months even without treatment 1, 2
• Patients with incomplete paralysis have higher recovery rates, up to 94% 1, 2
• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 1, 2

Potential Pitfalls to Avoid

• Starting acyclovir alone at any time point is ineffective and not recommended 1, 3, 4
• Starting steroid treatment beyond the 72-hour window provides minimal benefit and exposes patients to medication risks 2, 3
• Failing to provide adequate eye protection for patients with impaired eye closure can lead to corneal damage 1, 2
• Not referring patients with incomplete recovery after 3 months for specialist evaluation 1, 2