Original Article
doi: 10.1111/joim.12288
Steroid plus antiviral treatment for Bell’s
palsy
H. M. Kang, S. Y. Jung, J. Y. Byun, M. S. Park & S. G. Yeo
From the Department of Otorhinolaryngology, School of Medicine, Kyung Hee University, Seoul, Korea
Abstract. Kang HM, Jung SY, Byun JY, Park MS, Yeo
SG (Kyung Hee University, Seoul, Korea). Steroid
plus antiviral treatment for Bell’s palsy. J Intern
Med 2015; 277: 532–539.
Objectives. The effectiveness of antiviral agents for the
treatment of Bell’s palsy is uncertain. We evaluated
whether a steroid with an antiviral agent (S + A
group) provided better recovery outcomes than a
steroid alone (S group) in patients with Bell’s palsy.
Subjects and design. A total of 1342 patients diagnosed
with Bell’s palsy who visited the Kyung Hee
Medical Center in Seoul, Korea, from 2002 to
2012 were included in this study. Patients in the
S + A group were treated with prednisolone and
antiviral agents (n = 569) and those in the S group
with prednisolone alone (n = 773). Outcomes were
measured using the House–Brackmann (HB) scale
according to age, initial disease severity, electro-
neurography (ENoG) findings and underlying com-
orbidities.
Results. The rate of recovery (HB grades I and II) with
initially severe Bell’s palsy (HB grades V and VI)
was higher in the S + A than in the S group
Introduction
Bell’s palsy is an acute peripheral facial paralysis
of unknown cause, with an annual incidence of
11–40 per 100 000 [1, 2]. Its cause remains
unknown, although the findings of many studies
have suggested that it is primarily due to viral
infection, including infection with herpes simplex
(HSV), Epstein–Barr and varicella zoster viruses
[3–6]. In particular, the detection of HSV in the
human geniculate ganglion and of the HSV genome
in endoneurial fluid in Bell’s palsy patients
strongly suggests that infection with HSV can
cause Bell’s palsy [7–9]. In addition to persistent
inflammation from viral infection or an autoim-
mune response, oedema within the facial nerve
due to ischaemia can also cause facial palsy,
which can be worsened because the facial nerve
passes through a narrow bony canal [10].
Steroids, which decrease the swelling of the facial
nerve, are
(P = 0.001). However, the rates of recovery were
similar with initially moderate palsy (HB grades II–
IV) (P = 0.502). In patients classified according to
age and ENoG-determined severity of palsy, the
overall recovery rate was higher in the S + A than
in the S group, but the differences were not
statistically significant (P > 0.05 for both). The
recovery rate without diabetes mellitus (DM) and
hypertension (HTN) was higher in the S + A group
than in the S group (P = 0.031). But in the patients
with HTN and DM, the difference in recovery rates
between the S + A and S groups was not statisti-
cally significant (P = 0.805).
Conclusions. Treatment with a steroid plus antiviral
agent resulted in significantly higher recovery rates
than steroid therapy alone in patients with
initially severe Bell’s palsy and without either HTN
or DM, and a nonsignificant trend towards higher
recovery rates in all patients with Bell’s palsy in
this study. Antiviral agents may therefore help in
the treat- ment of Bell’s palsy.
Keywords: age, antivirals, Bell’s palsy, electroneurog-
raphy, severity, steroid.
considered first-line agents in the treatment of
Bell’s palsy [11, 12].
Despite the evidence for a role of viral infection, the
therapeutic efficacy of antiviral agents for Bell’s
palsy remains unclear. It has been reported that
the combination of an antiviral agent and steroids
is more effective than steroids alone [13]; however,
other studies demonstrated that both antiviral
agents alone and the combination of an antiviral
and a steroid were not effective with regard to
improving recovery from Bell’s palsy [14]. It was
also reported that the combination of an antiviral
agent and a steroid yielded better outcomes than
the use of a steroid alone in patients with severe or
complete Bell’s palsy [15]. The most recent guide-
lines from the American Academy of Neurology
suggest that acyclovir combined with prednisone is
‘possibly effective’ for the treatment of Bell’s palsy
[16]. Although the therapeutic efficacy of antiviral
H.532M. Kang
ª 2014 et
The al.
Association for the Publication of the Journal of Internal Medicine Steroid plus antiviral treatment
ª 2014 The Association for the Publication of the Journal of Internal Medicine
2121
Journal of Internal Medicine, 2015, 277; 532–539
agents in the resulting from other 2400 mg day 1 for 5 tion, possible very
treatment of Bell’s causes, such as the days, or the antiviral slight synkinesis),
palsy is still unclear, presence of a famci- clovir was grade ≤4 moderate
the clinical use of vesicular eruption of administered at palsy and grade ≥5
an antiviral–steroid the auricle or 750 mg day 1 for severe palsy. The
combination for the tympanic membrane 7 degree of facial palsy
treatment of Bell’s or a defined lesion of at the end-point of
palsy is increasing. the cerebellopon- tine d ‘recovery’ (i.e. no
angle or central a further improvement
This study was nervous system by y in facial palsy) was
designed to brain or temporal s also measured using
determine the thera- magnetic resonance . the HB grading
peutic efficacy of imaging, as well as system based on four
antiviral agents in patients with a The degree of facial different facial states
Bell’s palsy patients history of middle ear palsy was measured (at rest, eye closure
classified according to disease (e.g. chronic using the House– with maximal effort,
age, initial severity of otitis media), were Brackmann (HB) forehead wrinkling
disease, excluded. The study grading system with max- imal effort
electroneurography protocol was [17], which assigns and raising mouth
(ENoG) findings and approved by the patients to one of the angle with maximal
underlying institutional review six categories based effort). A good
comorbidities. board, and all on the degree of outcome or complete
patients provided facial function. recovery was defined
written informed Grade 1 indicates as HB grade ≤2.
S normal function,
consent.
u
grade 2 mild dysfunc- ENoG was performed
b
Patients with Bell’s tion (slight weakness 7–14 days after the
j
palsy were treated noticeable on close onset of symptoms
e
c with either oral inspec- using a Digitimer
t prednisolone alone or DS7A stimulator
s oral prednisolone (Biologic System,
plus an oral antiviral Sydney, Australia).
agent, and the The facial nerve in
a
therapeutic out- the area around the
n
comes of the two stylomastoid foramen
d
treatment regimens was stimulated with
were com- pared. a bipolar surface
m Adults (aged ≥16 electrode, and the
e years) were treated
t compound muscle
with prednisolone for action potential was
h
o 2 weeks: 80 mg day 1 measured. Results of
d for the first ENoG were reported
s 4 days, then 60 mg as the maximal
day 1 for 2 days, 40 amplitude of the
All patients with mg day 1 affected side of the
facial palsy who for 2 days, 20 mg face/ maximal
visited the outpatient day 1 for 2 days amplitude of a healthy
clinic of the and side of the face (%).
Department of 10 mg day 1 for 4
Otolaryngol- ogy at days. Children (age
Kyung Hee Medical ≤15 years) S
Center, a tertiary t
and low-weight
teach- ing hospital, a
adults were
from January 2002 t
started on
i
to December 1 mg kg 1 day 1 oral
s
2012, were enrolled in prednisolone, and the
t
this study. Bell’s dosage was gradually i
palsy was diagnosed decreased thereafter. c
as a sudden onset of The antiviral a
unilateral facial agent acyclovir l
paralysis. Patients was administered
with22 facial paralysis
ª 2014 The at 1000–
Association for the Publication of the Journal of Internal
Medicine
Journal of Internal Medicine, 2015, 277; 532–539
a excluded because
n they did not
a receive steroid
l therapy (n = 72), the
y data from their
s medical records were
i inadequate (n = 33),
s they were lost to
Groups were follow-up (n = 24) or
compared using because of other
Student’s t-test and central nervous
Mann–Whitney U- system disorders (n
test and chi- = 3). Of the 1342
squared test, as included patients
appropriate. To (Fig. 1), 773 (57.6%)
assess the effects of received a steroid
combination therapy alone and 569
and initial HB grade, (42.4%) received a
multivariate logistic combina- tion of a
regression analyses steroid and an
were performed antiviral agent. The
adjusted for the steroid alone group
effects of sex, age consisted of 351
and initial ENoG (45.4%) male patients
value, because the and 422 (54.6%)
analyses were female patients; the
stratified according respective patient
to the presence of numbers in the
hypertension (HTN) combination therapy
and/or diabe- tes group
mellitus (DM), in
line with some
previous studies in
which the effects of
these comorbidities
on recovery rate
were reported. All
statistical analyses
were performed
using SPSS (18.0;
SPSS Inc., Chicago
IL, USA), with
statistical
significance defined
as a P-value <0.05.

R
e
s
u
l
t
s
A total of 1474
patients with Bell’s
palsy visited the
outpatient clinic at
our hospital over the
11-year study period.
In total, 132 of these
patients were ª 2014 The Association for the Publication of the Journal of Internal Medicine
2323
Journal of Internal Medicine, 2015, 277; 532–539
H. M. Kang et al. Steroid plus antiviral treatment

1474 patients with Bell’s palsy

132 were excluded

72 were not treated with steroid
33 had insufficient medical records
24 were lost to follow-up
3 were diagnosed with another central nervous system disorder

1342 patients with Bell’s palsy included

569 patients were treated with steroid plus antiviral (acyclovir, famciclovir)

24 ª 2014 The Association for the Publication of the Journal of Internal

Medicine
Journal of Internal Medicine, 2015, 277; 532–539
 age severity of Bell’s palsy electroneurography findings
H. M. Kang et al.
Evaluation of recovery rate of Bell’s palsy according to treatment modalities
Steroid vs. steroid plus antiviral
were 284 (49.9%) and 285 (50.1%). Of the patients
in the steroid group, 48 (6.2%) were children (age
≤15 years), 634 (82.0%) were adults (age 16–
64 years) and 91 (11.8%) were elderly individuals
(age ≥65 years); in the combination group, the
corresponding numbers of patients were 10
(1.8%), 469 (82.4%) and 90 (15.8%). The initial
HB grade on admission was 3.59 0.98 in the
steroid group and 3.65 0.96 in the combination
group (P = 0.067), and the final HB grade 6
months after treatment in these two
groups was
1.72 0.74 and 1.74 0.78,
respectively (P = 0.183). Severe facial palsy (HB
grade ≥5) was observed in 161 patients (20.8%)
in the steroid group and 113 (19.9%) in the
combination group. ENoG analysis as a
prognostic indicator showed that 51 patients
(6.6%) in the steroid group and 35 (6.2%) in the
combination group had a poor prog- nosis (ENoG
value <10%). The steroid alone and combination
groups included 466 (60.3%) and 324 (56.9%)
patients, respectively, with neither HTN nor DM;
there were also 227 (29.4%) and 157 (27.6%)
patients with HTN alone, two (0.3%) and 34 (6.0%)
with DM alone and 78 (10.1%) and 54 (9.5%) with
both diseases, respectively (Table 1).
House–Brackmann grading after the 6-month fol-
low-up showed that 671 patients (86.8%) in the
steroid group and 510 (89.6%) in the combination
group achieved complete remission (P = 0.115)
(Table 2). When therapeutic results were assessed
with respect to age, we found that 44 children
(91.7%) in the steroid group and 10 (100%) in the
combination group recovered completely; complete
recovery was also observed in 550 (86.8%) and 419
(89.3%) adults (P = 0.193) and 77 (84.6%) and 81
underlying comorbidities
Steroid plus antiviral treatment
Fig. 1 Study population and
study design.
(90%) elderly patients, respectively (P = 0.277).
Although better therapeutic results were observed
in the combination group, the differences were not
statistically significant.
Of patients with mild-to-moderate facial palsy (HB
grade ≤4), 564 (92.2%) in the steroid group and
415 (91.0%) in the combination group recovered
com- pletely (P = 0.502). By contrast, recovery
from severe facial palsy (HB grade ≥5) was
observed in
105 (65.2%) patients in the steroid group and 95
(84.1%) in the combination group (P = 0.001).
Complete recovery was observed in 614 (87.1%)
patients in the steroid group and 438 (89.6%) in
the combination group with an ENoG value ≥10%
(P = 0.193), and in 43 (84.3%) and 31 (88.6%),
respectively, with an ENoG value <10% (P = 0.576)
(Table 3).
Amongst patients with HTN, 271 in the steroid
group (88.9%) and 188 (89.1%) in the combination
group recovered completely (P = 0.930). Complete
recovery was observed in 400 (85.5%) patients in
the steroid group and 322 (89.9%) in the combi-
nation group without HTN (P = 0.055), in 70
(87.5%) and 75 (85.2%), respectively, with DM
(P = 0.669) and in 601 (86.7%) and 435 (90.4%),
respectively, without DM (P = 0.052). Thus, the
therapeutic results were not affected by the pres-
ence or absence of HTN and DM. Amongst patients
with both HTN and DM, 69 (88.5%) in the steroid
group and 47 (87.0%) in the combination group
recovered completely (P = 0.805); amongst patients
without HTN or DM, 399 (85.6%) and 294 (90.7%),
respectively, recovered completely (P = 0.031)
(Table 4).
ª 2014 The Association for the Publication of the Journal of Internal Medicine
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Journal of Internal Medicine, 2015, 277; 532–539
Table 1 Baseline characteristics and outcome measurements in patients with Bell’s palsy

Steroid Steroid + Antiviral agent P-value

Patients, n (%) 773 (57.6) 569 (42.4) –
Sex –
Male : female, n 351 : 422 284 : 285
(%) (45.4 : 54.6) (49.9 : 50.1)
Age group, n (%) –
Children 48 (6.2) 10 (1.8)
Adults 634 (82.0) 469 (82.4)
Elderly 91 (11.8) 90 (15.8)
Initial HB grade (mean SD) 3.65 0.96 3.50 1.00 0.067
Final HB grade (mean SD) 1.74 0.78 1.69 0.68 0.183
Facial palsy, n (%)
Moderate 612 (79.2) 456 (80.1) –
Severe 161 (20.8) 113 (19.9) –
ENoG value, n (%) –
≥10% 705 (93.3) 489 (93.3)
<10% 51 (6.8) 35 (6.7)
Underlying comorbidity (HTN/DM), n (%) –
Neither 466 (60.3) 324 (56.9)
HTN 227 (29.4) 157 (27.6)
DM 2 (0.3) 34 (6.0)
HTN + DM 78 (10.1) 54 (9.5)

HB, House–Brackmann; ENoG, electroneurography; HTN, hypertension; DM, diabetes mellitus.

Table 2 Recovery rates in patients with Bell’s palsy with incomplete recovery (OR 0.16, 95% CI 0.103–
0.263). In patients with either HTN or DM, initial
Steroid + severe facial palsy was significantly associated
antiviral with a low OR of complete recovery (OR 0.32,
Steroid agent P-value 95% CI 0.167–0.611). In patients with both HTN
Complete 671 (86.8) 510 (89.6) 0.115 and DM, initial HB grade and combination therapy
remission, were not associated with complete recovery
(Table 5).
n (%)
Incomplete 102 (13.2) 59 (10.4)
remission, Discussion
n (%) Idiopathic facial palsy (Bell’s palsy) has a high rate
of spontaneous recovery (approximately 50–85%)
although its cause is not clear [14, 18]. A variety of
therapeutic approaches have become available,
Table 5 shows the adjusted odds ratio (OR) for the but the efficacy of definitive therapies remains
effects of antiviral therapy on complete recovery, unknown. Microsurgical exploration of the facial
adjusted for the presence of HTN and/or DM. In nerve at various stages of facial palsy has revealed
patients without either comorbidity, steroid–antiv- marked oedema during the acute phase [19, 20].
iral combination therapy moderately increased the Steroids may inhibit nerve swelling in the fallopian
OR for complete recovery [OR 1.59, 95% confidence canal and decrease vascular compression, result-
interval (CI) 0.972–2.607]. In addition, initial ing in the recovery of blood circulation to the nerve.
severe facial palsy (HB grade ≥5) was associated Steroid treatment has been shown to be effective in
Table 3 Therapeutic responses in patients with Bell’s palsy: effect of age, initial grade, ENoG value and treatment modality

Steroid Steroid + antiviral agent P-value

Age group
Children 48 10
Complete remission 44 (91.7%) 10 (100%) 0.344
Incomplete remission 4 0
Adults 634 469
Complete remission 550 (86.8%) 419 (89.3%) 0.193
Incomplete remission 84 50
Elderly 91 90
Complete remission 77 (84.6%) 81 (90%) 0.277
Incomplete remission 14 9
Initial HB grade
Moderate (HB grade ≤4) 612 456
Complete remission 564 (92.2%) 415 (91.0%) 0.502
Incomplete remission 48 41
Severe (HB grade ≥5) 161 113
Complete remission 105 (65.2%) 95 (84.1%) 0.001
Incomplete remission 56 18
ENoG value
≥10% (moderate) 705 489
Complete remission 614 (87.1%) 438 (89.6%) 0.193
Incomplete remission 91 51
<10% (severe) 51 35
Complete remission 43 (84.3%) 31 (88.6%) 0.576
Incomplete remission 8 4

HB, House–Brackmann; ENoG, electroneurography.

many studies of Of these 1342
patients with Bell’s subjects, 773
palsy [11, 12, (57.6%) were treated
18]. In addition, the with steroid alone
neuronal and 569 (42.4%)
inflammation asso- with a combi- nation
ciated with Bell’s of a steroid and an
palsy is thought to be antiviral agent, with
secondary to viral 86.8% and 89.6%,
infection, with HSV respectively,
detected in the endo- achieving complete
neural fluid of many recovery; this
patients [21]. finding was
Increasingly, these consistent with our
patients are being previous results [22].
treated with a
combination of a The efficacy of steroid
steroid and an therapy alone and in
antiviral agent. We com- bination with
have shown an antiviral agent
previously that the has not been
combination of a clearly established.
steroid and acyclovir Comparison
is more effective between studies is
than steroid alone, difficult because of
especially in patients the use of different
with severe Bell’s standards to define
palsy [22, recovery in patients
23]. However, the with Bell’s palsy [20],
therapeutic effects of different systems to
antiviral agents for grade disease
Bell’s palsy remain severity and
unclear. We therefore treatment with
compared the several different
efficacy of antiviral antiviral agents. In
agents plus a steroid addition, the small
with steroid therapy population sizes of
alone in Patients with many stud- ies, due
Bell’s palsy classified to the low incidence of
by several clinical Bell’s palsy, and the
variables. lack of homogeneity
amongst multicentre
We assessed the studies may
baseline confound study
characteristics and results. We used the
out- come measures HB grading system,
of facial palsy in which is most
1342 patients treated frequently used to
over a 11-year period
at a single hospital.
Table 4 Therapeutic responses in patients with Bell’s palsy: effect of underlying comorbidities

Steroid Steroid + antiviral agent P-value

HTN
With HTN 305 211
Complete remission 271 (88.9%) 188 (89.1%) 0.930
Incomplete remission 34 23
Without HTN 468 358
Complete remission 400 (85.5%) 322 (89.9%) 0.055
Incomplete remission 68 36
DM
With DM 80 88
Complete remission 70 (87.5%) 75 (85.2%) 0.669
Incomplete remission 10 13
Without DM 693 481
Complete remission 601 (86.7%) 435 (90.4%) 0.052
Incomplete remission 92 46
HTN + DM
With HTN + DM 78 54
Complete remission 69 (88.5%) 47 (87.0%) 0.805
Incomplete remission 9 7
Without HTN + DM 466 324
Complete remission 399 (85.6%) 294 (90.7%) 0.031
Incomplete remission 67 30

HTN, hypertension; DM, diabetes mellitus.

evaluate the degree of antiviral agents can
facial nerve damage provide consistent
in Bell’s palsy. HB treatment results in
grade ≤II was patients with Bell’s
defined as complete palsy.
recovery, although
stricter criteria set ENoG is a
grade I as complete neurophysiological
recovery. HB grades I method used to
and II have been evaluate the degree
used to indicate of injury of facial
‘favourable effects’, nerves and is the
‘satisfactory most frequently used
outcomes’, ‘good prognostic indicator
outcomes’ and for patients with
‘complete recovery’ in Bell’s palsy. The
previous studies by effects of treatment
us and others, as were assessed
patients with grade II separately in
are able to function patients with good
normally in daily life (ENoG value ≥10%)
[24–27]. We also and poor (ENoG
defined favourable or value <10%)
complete recovery as prognosis [28, 29].
HB grades I and II. Again, better
therapeutic results
Acyclovir and were observed in the
famciclovir are the combination group,
antiviral agents although the
commonly used to differences were not
treat patients with statistically sig-
Bell’s palsy. The nificant. The initial
therapeutic outcomes severity of facial
of antiviral agents nerve dys- function
were assessed in in Bell’s palsy has
patients divided by been reported to
age into three adversely affect
groups: children (age prognosis [30], as
≤15 years), adults well as having a
(age 16– direct effect on
64 years) and elderly antiviral efficacy [15,
individuals (age ≥65 23]. We found no
years). Although the difference in
therapeutic effects of recovery rates in
combination patients with
treatment were better moderate facial palsy
than those of steroid (HB grade ≤4) treated
alone in each of these with steroid alone
age groups, as well or combination
as in the overall therapy. In patients
patient cohort, none with severe facial
of these differences palsy (HB grade ≥5),
was sta- tistically a higher rate of
significant. This recovery was
result suggests that observed in the
combi- nation group
compared with the
steroid group.
Table 5 Adjusted OR of complete recovery amongst patients with Bell’s palsy

Neither DM nor HTN Either DM or HTN Both DM and HTN

OR 95% CI OR 95% CI OR 95% CI
Initial HB grade (moderate : severe) 0.16 0.103–0.263 0.32 0.167–0.611 1.58 0.328–7.653
Sex (male : female) 0.98 0.614–1.550 0.93 0.491–1750 1.35 0.452–4.057
Treatment (steroid : steroid + antiviral) 1.59 0.972–2.607 1.05 0.554–1.972 0.79 0.266–2.378
Electroneurography (≥10% : <10%) 0.65 0.280–1.496 1.69 0.375–7.605 0.58 0.111–3.079
Age 0.98 0.960–0.992 1.01 0.797–1.047 1.00 0.941–1.058

DM; diabetes mellitus, HTN; hypertension; HB, House–Brackmann; OR, odds ratio; CI, confidence interval.
These results are bination treatment of the vasa nervosum g
consistent with those were similar in [34]. Disorders of the e
of earlier studies [15, patients with DM, microcirculation m
23] and provide a but combination appear to undermine e
rationale for the use treatment resulted in the effects of n
of antiviral agents in higher recovery rates antiviral agents in t
the treatment of in patients without patients with HTN This work was
severe Bell’s palsy. DM (P = 0.052) and and/or DM. supported by the
significantly higher National Research
Hypertension and recovery rates in In summary, we Foundation of Korea
DM are underlying patients with neither found that (NRF) grant funded
comorbidi- ties that HTN nor DM (P = therapeutic outcomes by the Korean
can affect the 0.031). Multivariate were better with government (No.
prognosis of patients logistic regression steroid–antiviral 2011-0030072).
with Bell’s palsy. analyses showed combination therapy
Some evidence has that combi- nation than with steroid
suggested that HTN therapy in patients treatment alone in C
improves the without DM or HTN patients without HTN o
prognosis of these increased the OR or DM, and in n
patients [31], value with marginal patients with initially f
whereas no effect of significance (OR severe Bell’s palsy. l
HTN has also been 1.59, 95% CI 0.972– Combination therapy i
demon- strated [25]. 2.607, P = 0.063), was also effective in c
Similarly, DM has sug- gesting that groups classified by t
been reported to be combination therapy other variables,
unrelated to the in these patients may including age, ENoG o
prognosis of Bell’s aid recovery. That is, value and underly- f
palsy [30], whereas antiviral agents were ing comorbidities.
other studies have more effective in Our findings i
found that DM wors- treating Bell’s palsy provide further n
ens prognosis [32, in patients without evidence for the t
33]. Although than those with HTN ‘possible e
earlier studies and DM. This may be effectiveness’ of r
addressed the due to the antiviral agents and e
relationship between associations between support the clinical s
HTN and DM and HTN and DM and application of this t
the prognosis of microangiopathy, treatment, in patients
Bell’s palsy, in the according to the with Bell’s palsy. s
present study, we theory that Bell’s t
investigated the palsy is caused by The recovery rate in a
effects of different microcirculatory patients receiving t
therapeutic failure combination e
approaches in the treatment was m
presence or absence generally higher than e
of these underlying in patients treated n
t
conditions. Recovery with steroid alone,
rates were similar in providing evidence No
HTN patients treated for the efficacy of confl
with steroid alone or antiviral therapy in icts
combination therapy, the treatment of Bell’s of
although slightly palsy. inter
improved recovery est to
rates were observed decl
in patients without A are.
HTN treated with c
combination therapy k
compared with n
o R
steroid alone (P = e
w
0.055). Therapeutic f
l
responses to steroid e
e
alone and com- r
d
e
n
c
e
s
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