Concierge neurology · London
Punch biopsy for small fibre neuropathy, gold-standard diagnostic test for small fibre neuropathy.
A 3 mm skin punch biopsy from the distal leg quantifies intraepidermal nerve fibre density (IENFD) — the gold-standard test for small fibre neuropathy (SFN) causing burning feet, temperature intolerance and autonomic symptoms.
Why patients choose us
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The right hands
We route you to a consultant neurologist with small fibre neuropathy expertise — the person who reads the biopsy decides the answer.
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Results in 2–3 weeks
Same-day procedure under local anaesthetic, with a structured IENFD report from a specialist neuropathology lab.
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Independent, and free
We are paid by no clinic, so the recommendation is impartial and costs you nothing.
Key facts
The essentials, in six lines.
What the punch biopsy is, how it’s done, and what it measures — enough to make the rest of the page make sense.
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Definition
A skin punch biopsy that quantifies intraepidermal nerve fibre density (IENFD).
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15-minute procedure under local anaesthetic
Sterile, in-clinic, with minimal discomfort.
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3 mm punch from the distal leg
Standard site is 10 cm above the lateral malleolus.
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IENFD counted per millimetre
Fibres are quantified against age- and sex-matched normative data.
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Complements QST and autonomic testing
Sits alongside quantitative sensory and autonomic function studies.
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Same-day procedure, results in 2–3 weeks
Immunohistochemistry and reporting take a fortnight at a specialist lab.
How it works
From consultation to structured plan — what happens, in order.
One clinician from the first consultation through to the reported IENFD and treatment plan.
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Neurology consultation
A consultant neurologist confirms clinical suspicion of small fibre neuropathy and rules out alternatives.
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Skin marking (distal leg)
The standard site — 10 cm above the lateral malleolus on the distal leg — is cleaned and marked.
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Local anaesthetic
A small volume of lidocaine numbs the site — a brief sting, then nothing.
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Punch sample
A 3 mm circular skin punch is taken and placed straight into fixative.
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Bright-field immunohistochemistry (PGP 9.5)
The specialist lab stains for the pan-axonal marker PGP 9.5 to make small fibres visible.
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IENFD counted per mm
Nerve fibres are counted per millimetre of epidermis and compared to normative ranges.
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Structured plan
Your neurologist explains the result and sets a treatment and follow-up plan.
What it shows
When a punch biopsy is the right test.
The biopsy answers a specific question — is there measurable small fibre loss, and does the pattern point to a cause. These are the presentations we see most.
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Reduced IENFD (below normative range)
The core positive finding — low intraepidermal nerve fibre density confirms small fibre neuropathy.
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Length-dependent SFN pattern
Classic picture — worst in the distal leg, in keeping with metabolic or idiopathic SFN.
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Non-length-dependent SFN
Proximal or patchy loss — often points to immune-mediated or paraneoplastic causes.
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Sudomotor dysfunction (autonomic SFN)
Reduced sweat-gland innervation — a marker of autonomic small fibre involvement.
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Post-COVID SFN
A recognised post-viral pattern presenting with burning pain and autonomic symptoms.
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Diabetic SFN
Common driver — quantifies small fibre loss even when nerve conduction studies are normal.
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Sjögren’s SFN
A classic non-length-dependent pattern seen in primary Sjögren’s syndrome.
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Red flag: acute autonomic SFN — urgent neurology
Rapid autonomic decline warrants urgent specialist review, not a routine slot.
Treatment
What follows the diagnosis.
Treating the cause where one is found, alongside evidence-based symptomatic and supportive care.
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Treat underlying cause (diabetes, Sjögren’s)
Tight glycaemic control or immunomodulation aimed at the driver, not just the symptom.
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Gabapentin / pregabalin
First-line neuropathic analgesics for burning pain and paraesthesia.
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Duloxetine
SNRI with strong evidence in painful small fibre neuropathy.
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Topical lidocaine / capsaicin
Local options for focal painful areas with a favourable side-effect profile.
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Autonomic support (fludrocortisone)
For orthostatic intolerance where autonomic involvement is prominent.
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Physiotherapy for reconditioning
Graded activity to counter deconditioning and improve function.
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Structured neurology follow-up
Titration, monitoring and repeat testing where the picture evolves.
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Multi-disciplinary team review
Neurology, pain, rheumatology and autonomic input coordinated around one plan.
Red flags
When SFN needs urgent, not routine, review.
Most SFN is chronic and manageable. These patterns change the tempo — they warrant same-week neurology, not a scheduled slot.
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Acute autonomic SFN
Rapid-onset autonomic failure — urgent neurology, not a routine slot.
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Rapidly progressive SFN
Escalating deficit over weeks warrants same-week specialist review.
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Post-COVID SFN with autonomic collapse
Severe orthostatic intolerance after COVID needs urgent assessment.
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Sjögren’s with vasculitis
Consider systemic vasculitis when Sjögren’s presents with mononeuritis multiplex.
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Amyloid neuropathy
Painful SFN with autonomic and cardiac features — screen for hereditary and AL amyloid.
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Paraneoplastic SFN
Subacute non-length-dependent SFN — investigate for occult malignancy.
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Post-chemotherapy SFN
Cumulative neurotoxicity from platinum, taxane or bortezomib agents.
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Post-immunotherapy SFN
Checkpoint-inhibitor-associated neuropathy — coordinate with oncology.
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Post-vaccination SFN (rare)
Very uncommon association — investigate other causes first.
Sources
Guidelines behind this page.
The evidence base — the guidelines this guide was written against.
- European Federation of Neurological Societies. Guidelines on the use of skin biopsy in the diagnosis of small fibre neuropathy.
- American Academy of Neurology. Evidence-based guideline: diagnosis of distal symmetric polyneuropathy.
- British Peripheral Nerve Society. Position statements on small fibre neuropathy assessment.
- NICE. Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173).
Reviewed by Pulse Atlas Editorial Board, . Published 2026-07-30. Next review 2027-07-30. Estimated reading time 5 minutes.
Recognised by major UK insurers
Cover depends on your policy and clinic; we confirm with your insurer before booking.
Frequently asked
Everything patients ask about punch biopsy for SFN.
Quick answers on what the test measures, discomfort, timing, referrals, autonomic testing and risks.
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What does a punch biopsy for small fibre neuropathy show?
A 3 mm skin punch from the distal leg is stained for PGP 9.5 and the intraepidermal nerve fibre density (IENFD) is counted per millimetre. A reduced IENFD below age- and sex-matched normative values confirms small fibre neuropathy.
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Is the punch biopsy painful?
The site is numbed with local anaesthetic, so the procedure itself is largely painless. You feel a brief sting from the anaesthetic, then pressure. Mild soreness for a day or two afterwards is normal.
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How long do results take?
The procedure itself takes about 15 minutes. Immunohistochemistry, counting and reporting at a specialist neuropathology lab typically take 2–3 weeks.
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Do I need a referral?
A neurology consultation is required first — the biopsy is only useful in the context of a specialist assessment. We can arrange the consultation and biopsy together.
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When is autonomic testing added?
When symptoms suggest autonomic involvement — orthostatic dizziness, sweating changes, gastrointestinal or bladder disturbance — autonomic function testing complements the biopsy.
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What are the risks?
A 3 mm punch heals with a small mark. Infection is rare with sterile technique, bleeding is minimal, and stitches are usually not required.
Related tests
Looking for a different test?
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In practice, in London
How punch biopsy small fibre neuropathy tends to unfold when you go private
With punch biopsy small fibre neuropathy, the London question is usually about report turnaround and the radiologist reading it — not whether the scan is available. Public provision for punch biopsy small fibre neuropathy is competent but constrained by capacity. Private London clinics tend to have shorter diaries and longer appointment slots, so you get the same specialists with more time. For people who’ve been going round in circles with primary care, that first proper conversation is often what shifts things.
A typical private booking for punch biopsy small fibre neuropathy in London starts with a consultant conversation — sometimes in person on Harley Street or Marylebone, sometimes on video if that suits better. Any imaging or diagnostics happen at a nearby CQC-registered facility, and reports usually land within 24 to 72 hours. The whole loop, from first call to written report, is often done inside a fortnight. For punch biopsy small fibre neuropathy specifically, the difference between a routine report and a sub-speciality read is where private care earns its keep.
Where a good concierge earns its keep is in the matching. There are dozens of consultants in London who see punch biopsy small fibre neuropathy — but not all of them are the right fit for every case. We narrow it down based on subspecialty, insurer coverage, the specific question being asked, and whether continuity into treatment matters. The right first appointment saves you from repeating yourself later.
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