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Skin biopsy, QST and the diagnosis of burning pain without numbness
Small fiber neuropathy affects the smallest nerve fibers — causing burning pain and temperature sensitivity without numbness or weakness. Standard nerve tests are normal; skin biopsy is required for diagnosis.
Kathmandu Neurology Clinic & Cognitive Center
Authored and reviewed by Dr. Jitendra Prasad Yadav (MBBS, MD (Internal Medicine), FICN (Neurology), FCNV, FIHM, NMC 8029). Evidence-based, no fabricated outcomes.
Small fiber neuropathy affects the smallest nerve fibers — causing burning pain and temperature sensitivity without numbness or weakness. Standard nerve tests are normal; skin biopsy is required for diagnosis.
Reviewed by Dr. Jitendra Prasad Yadav, MBBS, MD, FICN, FCNV, FIHM — Consultant Neurologist & Headache Specialist (NMC 8029), Kathmandu Neurology Clinic. For evaluation, book an appointment.
Nerve conduction studies test large myelinated fibers. SFN affects small unmyelinated fibers carrying pain and temperature — invisible to NCS. Patients have normal strength, reflexes and touch sensation but severe burning pain.
Skin biopsy (3mm punch biopsy measuring intraepidermal nerve fiber density — definitive test), quantitative sensory testing (QST), autonomic testing, and laboratory workup for causes (glucose, B12, thyroid, autoimmune, monoclonal gammopathy). ~50% of cases are idiopathic.
Treat underlying cause (glucose control for diabetic SFN, immunotherapy for autoimmune), medications for neuropathic pain (gabapentinoids, SNRIs, TCAs, topical agents), autonomic symptom management, and pain management strategies.
Lauria G et al. EFNS guidelines on neuropathic pain assessment. Eur J Neurol 2010Content on this website is for general educational purposes only and does not constitute medical advice, diagnosis, or treatment. It is not a substitute for evaluation by a qualified healthcare professional. Always seek the advice of your physician or other qualified provider with any questions regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have read on this website. In case of a medical emergency, contact emergency services immediately. No doctor–patient relationship is established by use of this site or by contacting the clinic through the site.