Small Fiber Neuropathy Differential Diagnosis and Treatment Implications

Burning sensation in the feet is a common problem encountered in podiatric medicine. When this pain is bilateral, symmetric, and includes the top and bottom of both feet, small nerve fiber involvement must be considered in the differential diagnosis. With the now available, in-office, skin biopsy quantification of intraepidermal nerve fibers, documentation of the presence of small fiber involvement in the pain mechanism is possible. Technical details of performing the skin biopsy are reviewed and the legal implications of a positive abnormal skin biopsy for intraepidermal nerve fibers is discussed.