Management of Small Fiber Neuropathy: A Clinical Perspective

Small fiber neuropathy (SFN) is a common neurological diagnosis with a multitude of symptoms, including dysautonomia symptoms (e.g., orthostatic dizziness) as well as sensory disturbances, such as a tingling sensation or burning pain. The disease can be due to metabolic, autoimmune, or hereditary factors, and treatment plans stem from SFN etiology. Diabetes, autoimmune disease, infection, vitamin deficiencies, post-vaccination syndromes can all cause SFN. Needle electromyography and nerve conduction studies can be performed to exclude other neuromuscular conditions by ruling out large fiber neuropathies. The gold standard of diagnosis for SFN remains an abnormal skin biopsy. For non-idiopathic cases, treatment of underlying causes, including metabolic, nutritional, infectious, autoimmune, or toxin-related, is critical for symptom improvement. Most treatment options for idiopathic SFN are geared toward symptom management for neuropathic pain and paresthesia and include antiepileptics, antidepressants, and topical ointments. First-line medications include amitriptyline, nortriptyline, gabapentin, and pregabalin. Second-line treatments can include serotonin-norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors such as duloxetine and venlafaxine, as well as lidocaine patches and capsaicin.