Summary Background : Whether liver steatosis affects sustained virological response in patients with chronic hepatitis C is still under discussion. Aim : To evaluate the impact of liver steatosis in patients treated (for chronic hepatitis C) with combination therapy. Methods : We evaluated 97 (male/female 82/15, mean age 41.1 years) consecutive naïve patients treated with pegylated interferon alpha‐2b plus ribavirin. Results : Prevalence and severity of liver steatosis were significantly associated with genotype 3a grade 3–4 in 14 of 32 patients (44%) vs. 8 of 65 patients (12%) with other genotypes; P = 0.001, while steatosis grade 1 (<10% of hepatocytes affected) was more frequently associated with genotype 1a/1b 9/39 (23%) vs. 4/57 (7%); P = 0.02. Overall, sustained virological response was 62.8%, and was statistically uninfluenced by the presence/absence of liver steatosis. On the contrary, the following variables were independently associated with sustained virological response at logistic regression analysis: genotype other than 1a/1b, positive association, (odds ratio 3.4, P < 0.04), and low‐grade liver steatosis, negative association, (odds ratio 9.0, P =0.009), whereas sustained virological response was unaffected by severe liver steatosis, which was mainly associated with genotypes 2 and 3 steatosis grade 2, 18/29 (62%); grade 3, 10/12 (83%); grade 4, 7/10 (70%). Conclusions : Only low‐grade liver steatosis negatively affects the outcome of combination therapy, with peginterferon alpha‐2b plus ribavirin, while severe steatosis (which is virus‐related in most cases) has no impact on virological response.