Commentary: The potential of systemic immune-inflammation index in predicting outcomes of facial palsy in patients with Ramsay Hunt syndrome treated by acupuncture

We read with great interest the recent article by Fang et al. ( 1), which explored the role of the systemic immune-inflammation index (SII) as a predictor of acupuncture efficacy in patients with Ramsay Hunt syndrome (RHS)-related facial palsy. The authors should be commended for their pioneering investigation into a novel, readily accessible biomarker at the intersection of neuroinflammation, viral neuropathy, and complementary medicine. Their findings suggest that SII may serve as a useful tool for stratifying patients and personalizing treatment strategies-a promising step toward more objective assessment in acupuncture therapy for neurological disorders.we would like to engage in a constructive discussion regarding several methodological and interpretative aspects. The following commentary aims to elaborate on these points to help refine the conclusions and guide future research in this promising field.Although the authors describe a "standardized acupuncture protocol," the manual stimulation applied differed based on the time from symptom onset (mild stimulation within one week, stronger stimulation thereafter). This introduces a potential source of heterogeneity in treatment delivery. Variation in needle stimulation intensity has been shown to influence neuroimmune responses and clinical outcomes in facial palsy (2).For instance, stronger manual stimulation may activate distinct neural pathways, such as A-delta fibers and the descending pain modulatory system, which could differentially modulate local and systemic inflammation (3). Without quantifying or randomizing stimulation parameters, it remains challenging to ascertain whether the observed association between SII and outcomes is independent of this procedural variability.Future studies should consider employing electroacupuncture with standardized parameters (e.g., fixed frequency and intensity) to enhance reproducibility and mechanistic interpretation.All patients in the study received antiviral and corticosteroid therapy, yet the potential interaction between these treatments and SII was not explored in depth.Corticosteroids are potent immunomodulators that can rapidly alter neutrophil and lymphocyte counts-the very components of SII (4). A recent study by Chen et al. ( 5) demonstrated that dexamethasone administration significantly reduces SII within 48 hours in patients with acute inflammatory conditions. Therefore, the baseline SII measured in this study may not fully reflect the pre-treatment immune-inflammatory status but rather a partially modulated state. It would be valuable to analyze whether the time interval from corticosteroid initiation to SII measurement influenced the results, or to consider serial SII measurements during treatment to capture its dynamic nature as a biomarker.The study focused exclusively on host inflammatory markers without accounting for viral load or specific antiviral immune responses. In RHS, varicella-zoster virus (VZV) reactivation drives not only inflammation but also adaptive immune activation. The combination of SII and body mass index (BMI) in a predictive model yielded only a marginal increase in the area under the curve (AUC) (0.840 vs. 0.839). While the authors suggest this combination "may still offer additional prognostic insight," this interpretation warrants caution. The minimal improvement, coupled with the loss of BMI's statistical significance in the multivariate analysis, suggests that BMI adds limited value beyond SII alone in predicting acupuncture response. Furthermore, BMI is a crude measure of adiposity and may not accurately reflect visceral fat mass or proinflammatory adipose tissue activity. Future predictive models might benefit from incorporating direct measures of adipose-driven inflammation, such as leptin or