The Evaluation of Intraepidermal Nerve Fiber Density in Skin Biopsy – Normative Data

Authors: Š. Buršová1ihash2ihash4ihash6ihash8ihash10 ,2 ,2 ,2 ,3 ,2 ,2
Authors‘ workplace: Neurologická klinika LF MU a FN Brno 1;  CEITEC – Středoevropský technologický institut MU, Brno 2;  Anatomický ústav LF MU, Brno 3
Published in: Cesk Slov Neurol N 2012; 75/108(4): 455-459
Category: Original Paper


At present, evaluation of intraepidermal nerve fiber density (IENFD) from skin bio­psies represents one of the most important methods for diagnosing neuropathic pain and sensory neuropathies, particularly in small-fiber neuropathy patients. The aim of the study was to analyze the effects physiological variables may have on IENFD values and to establish valid IENFD normal limits for distal calf region. Furthermore, we evaluated the IENFD values from anterolateral proximal thigh samples in a pilot study with a small group of healthy individuals.

Patients and methods:
Skin biopsies from the distal calf were obtained from a group of 74 healthy individuals (39 men, 35 women, age: median 54.5 years, range 27–84 years). IENFD was established in all the samples using the indirect immunofluorescence method. The effect of age and gender on IENFD values was evaluated and age-stratified normal values were derived in subgroups of patients aged 20–40, 40–60 and 60+ years. In addition, IENFD values obtained from proximal thigh skin biopsies of 14 individuals were compared to the distal samples.

Significant age-related decrease in IENFD values and non-significant trend to higher IENFD values in women were found in distal skin biopsy samples. Lower normal limits in the respective age subgroups were set at 5.5–5.1–1.9 fi­bers per 1 mm in men and 6.1–5.2–3.1, respectively, in women. Compared to the distal samples, proximal IENFD values were significantly higher.

In a group of healthy volunteers, a significant effect of age and non-significant trend towards an effect of gender on IENFD values was found. Therefore, age-stratified and gender-specific normal values should be used when evaluating IENFD in distal skin biopsy samples. Comparison of these findings to proximal thigh samples confirms significant proximo-distal gradient of IENFD values.

Key words:
skin biopsy – intraepidermal nerve fiber density – normative values – healthy individuals – age stratification


1. Devigili G, Tugnoli V, Penza P, Camozzi F, Lombardi R, Melli G et al. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain 2008; 131(Pt 7): 1912–1925.

2. Lauria G, Hsieh ST, Johansson O, Kennedy WR, Leger JM, Mellgren SI et al. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. Eur J Neurol 2010; 17(7): 903–912.

3. Cruccu G, Sommer C, Anand P, Attal N, Baron R, Garcia-Larrea L et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol 2010; 17(8): 1010–1018.

4. Haanpää M, Attal N, Backonja M, Baron R, Bennett M, Bouhassira D et al. NeuPSIG guidelines on neuropathic pain assessment. Pain 2011; 152(1): 14–27.

5. Moravcová E, Bednařík J, Feit J, Sommer C. Hodnocení intraepidermální hustoty tenkých nervových vláken z kožní biopsie u pacientů s polyneuropatií. Cesk Slov Neurol N 2005; 68/101(4): 219–226.

6. Vlckova-Moravcova E, Bednarik J, Dušek L, Toyka KV, Sommer C. Diagnostic validity of epidermal nerve fiber densities in painful sensory neuropathies. Muscle Nerve 2008; 37(1): 50–60.

7. Bursova S, Dubovy P, Vlckova-Moravcova E, Nemec M, Klusakova I, Belobradkova J et al. Expression of growth-associated protein 43 in the skin nerve fibers of patients with type 2 diabetes mellitus. J Neurol Sci 2012; 315(1–2): 60–63.

8. Lauria G, Morbin M, Lombardi R, Borgna M, Mazzoleni G, Sghirlanzoni A et al. Axonal swellings predict the degeneration of epidermal nerve fibers in painful neuropathies. Neurology 2003; 61(5):


9. Gibbons CH, Griffin JW, Polydefkis M, Bonyhay I, Brown A, Hauer PE et al. The utility of skin biopsy for prediction of progression in suspected small fiber neuropathy. Neurology 2006; 66(2): 256–258.

10. Umapathi T, Tan WL, Loke SC, Soon PC, Tavintharan S, Chan YH. Intraepidermal nerve fiber density as a marker of early diabetic neuropathy. Muscle Nerve 2007; 35(5): 591–598.

11. Bakkers M, Merkies IS, Lauria G, Devigili G, Penza P, Lombardi R et al. Intraepidermal nerve fiber density and its application in sarcoidosis. Neurology 2009; 73(14): 1142–1148.

12. Lauria G, Bakkers M, Schmitz C, Lombardi R, Penza P, Devigili G et al. Intraepidermal nerve fiber density at the distal leg: a worldwide normative reference study. J Peripher Nerv Syst 2010; 15(3): 202–207.

13. Uçeyler N, Kafke W, Riediger N, He L, Necula G, Toyka KV et al. Elevated proinflammatory cytokine expression in affected skin in small fiber neuropathy. Neurology 2010; 74(22): 1806–1813.

14. Defrin R, Shachal-Shiffer M, Hadgadg M, Peretz C. Quantitative somatosensory testing of warm and heat-pain thresholds: the effect of body region and testing method. Clin J Pain 2006; 22(2): 130–136.

15. Buršová Š, Vlčková E, Hnojčíková M, Němec M, Bednařík J. Přístrojově asistované kvantitativní testování senzitivity – normativní data. Cesk Slov Neurol N 2012; 75/108(4): 444–453.

16. Pittenger GL, Ray M, Burcus NI, McNulty P, Basta B, Vinik AI. Intraepidermal nerve fibers are indicators of small-fiber neuropathy in both diabetic and nondiabetic patients. Diabetes Care 2004; 27(8): 1974–1979.

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