Small fiber neuropathy (SFN) is treated differently depending on the underlying cause and can lead to symptoms such as burning or shooting pain and hyperesthesia. The underlying cause of small fiber neuropathy must be treated together with any related neuropathic pain. When a person manages or receives treatment for the underlying medical condition, their neuropathy symptoms may improve or completely disappear. For the overall care of neuropathic pain, various recent guidelines suggest the use of antidepressants, opioids, topical therapies, and nonpharmacologic treatments.
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A wide range of conditions, including diabetes, thyroid dysfunction, and HIV, as well as other diseases, can lead to small fiber neuropathy. In some cases, the diagnosis of small fiber neuropathy can also be deemed as “idiopathic.” However, pain is frequently the most troublesome symptom of the condition regardless of the underlying cause. As a result, therapy is tailored to managing the pain symptoms as well as identifying and treating the underlying causes. This requires individuals with diabetes or other metabolic disorders to manage their blood sugar levels, maintain a healthy body weight, and consume a nutritious, balanced diet. Regular exercise and quitting smoking can aid in the healing of constricted blood vessels that transport vital nutrients to the nerves.
Immunosuppressive drugs may be prescribed to patients with autoimmune diseases. These medications inhibit the immune system and reduce inflammation. The key to improving symptoms and preventing the progression of small fiber neuropathy is etiology-specific treatment.
In SFN patients, there is emerging evidence that intravenous immunoglobulin (IVIG) can reduce pain and enhance objective nerve fiber densities on skin biopsies. Certain patients that are experiencing SFN with other etiologies may benefit from IVIG treatment which will allow the patient to experience relief.
A case series of Sjogren syndrome associated with SFN showed persistent improvement following IVIG treatment. In a large cohort study, IVIG also had therapeutic effects on small fiber neuropathy associated with sarcoidosis. Due to the limited population for participation in clinical trials, it may be challenging to conduct such studies. Future controlled studies will be required to determine whether autoantibody-associated idiopathic SFN responds to IVIG.
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Management of symptoms and measures to address the underlying cause of the neuropathy are the two main focuses of treatment for SFN. Symptom management focuses on reducing pain that is associated with small fiber neuropathy. Treatment options are selected based on the patient’s comorbidities, concurrent medications, and the patient’s safety profile. These treatment options include:
- Opioid or narcotic-based pain medications
- Lidocaine patches and creams
- Anti-seizure medications
- Smith AG, Russell J, Feldman EL, Goldstein J, Peltier A, Smith S, Hamwi J, Pollari D, Bixby B, Howard J, Singleton JR. Lifestyle intervention for pre-diabetic neuropathy. Diabetes Care. 2006 Jun;29(6):1294-9. doi: 10.2337/dc06-0224. PMID: 16732011.
- Pindi Sala T, Villedieu M, Damian L, Crave JC, Pautot V, Stojanovich L, Tervaert JWC, Cherin P, Belizna C. Long-term efficacy of immunoglobulins in small fiber neuropathy related to Sjögren’s syndrome. J Neurol. 2020 Dec;267(12):3499-3507. doi: 10.1007/s00415-020-10033-z. Epub 2020 Jul 1. PMID: 32613444.
- Tavee JO, Karwa K, Ahmed Z, Thompson N, Parambil J, Culver DA. Sarcoidosis-associated small fiber neuropathy in a large cohort: Clinical aspects and response to IVIG and anti-TNF alpha treatment. Respir Med. 2017 May;126:135-138. doi: 10.1016/j.rmed.2017.03.011. Epub 2017 Mar 9. PMID: 28318820.
- Geerts M, de Greef BTA, Sopacua M, van Kuijk SMJ, Hoeijmakers JGJ, Faber CG, Merkies ISJ. Intravenous Immunoglobulin Therapy in Patients With Painful Idiopathic Small Fiber Neuropathy. Neurology. 2021 May 18;96(20):e2534-e2545. doi: 10.1212/WNL.0000000000011919. Epub 2021 Mar 25. PMID: 33766992; PMCID: PMC8205474.
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Dr. Martina Mikail, PharmD was born in Egypt and raised in Pennsylvania and California. She graduated from Marshall B. Ketchum University in May 2022. Dr. Mikail is a recipent of the USPS Leadership Award and the CSHP Leadership Award, and is an active member of CSHP, ASHP, and APhA. The most rewarding part of her job is educating patients and counseling them on medications. In her free time, she likes to cook, spend time with family, and read.