What is the treatment for Ramsay Hunt syndrome?

Treatment of Ramsay Hunt Syndrome

Treat Ramsay Hunt syndrome with combination therapy of corticosteroids PLUS antivirals—never use antivirals as monotherapy—initiated as early as possible to optimize facial nerve recovery and prevent long-term complications. 1, 2

Primary Pharmacologic Treatment

The cornerstone of treatment is dual therapy combining corticosteroids with antiviral agents:

• Corticosteroid regimen: Oral prednisone 60 mg daily for 3-5 days is the standard approach 3

  • High-dose corticosteroid therapy (prednisolone 200 mg/day) combined with antivirals achieved 71.1% recovery rates in severe House-Brackmann grade VI cases, superior to normal-dose regimens (60% recovery) 4
  • The anti-inflammatory effect reduces facial nerve edema and minimizes nerve damage 5, 6

• Antiviral regimen: Choose one of the following 3:

  • Famciclovir 500 mg three times daily for 7-10 days, OR
  • Acyclovir 800 mg five times daily for 7-10 days

• Critical caveat: Avoid routine use of antivirals as monotherapy without corticosteroids—this approach lacks evidence support 1

Timing of Treatment Initiation

Early treatment is a significant predictor of favorable outcomes:

• Initiate therapy within 7 days of symptom onset for optimal facial palsy recovery 3, 4
• Treatment within 72 hours is ideal when possible 2
• Logistic regression analysis confirms that early treatment initiation is a significant factor impacting recovery 4

Clinical Monitoring and Audiologic Management

Vestibulocochlear nerve involvement requires systematic audiologic assessment:

• Perform audiometric evaluation at treatment conclusion 7, 1
• Repeat audiometric testing within 6 months to assess hearing recovery 7, 1
• Patients commonly experience tinnitus, hearing loss, vertigo, and nystagmus due to anatomic proximity of the geniculate ganglion to the eighth cranial nerve 7, 1, 3

Audiologic Rehabilitation

For patients with persistent symptoms after treatment:

• Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation benefits 7, 1
• Offer supportive measures for persistent vestibulocochlear symptoms 7

Important Clinical Pitfalls

Diagnostic timing considerations:

• 14% of patients develop vesicles AFTER facial weakness onset, making Ramsay Hunt syndrome initially indistinguishable from Bell's palsy 3
• Some patients have "zoster sine herpete" (facial paralysis without rash) but with VZV DNA detected in auricular skin, blood, or saliva—these patients still benefit from antiviral therapy 3
• Better recovery rates occur when herpetic vesicles appear before facial palsy rather than after 4

Treatment intensity for severe cases:

• For House-Brackmann grade VI (complete paralysis), consider high-dose corticosteroid therapy (prednisolone 200 mg/day) combined with antivirals for superior outcomes 4
• Severe paralysis at onset predicts less complete recovery compared to Bell's palsy 3