Skin biopsy: a new tool for diagnosing peripheral neuropathy
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39192.488125.BE (Published 31 May 2007) Cite this as: BMJ 2007;334:1159
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
We thank Dr. Povlsen for his comment on our paper, which gives us the
opportunity to emphasize the safety of skin biopsy. The inclination of the
figure may have been confounding. We are aware that a biopsy taken on the
radial aspect of the finger would likely injury the digital nerve branch.
In fact, biopsy of the finger must be performed on the palmar skin. The
picture shows the small scar of a 3-mm punch taken close to the midline of
the first phalange. We and other researchers have performed such biopsy in
several healthy subjects and patients with no side effect. In this region,
biopsy is safe, much easier and well tolerated than in the exact midline
of the finger or in the fingertip. The two main differences between biopsy
of the hairy skin and that of the finger performed as we have described
are that in the latter topical anaesthesia may be more painful and
bleeding may last longer.
Competing interests:
None declared
Competing interests: No competing interests
I much enjoyed the content of the article as I mostly see patients
with neurological problems of the hands in my clinical practice. However,
as a hand surgeon I was concerned about the fig. 3 bottom right photo
which seem to indicate that a skin bipsy had been taken from the radio-volar skin of the left index finger. My concern was accentuated by the
fact that in the summary points box it was suggested that a skin biopsy
was easy and almost painless. Furthermore, nowhere was there any
indication that potential injuries could be caused by the use of this
technique. I am of the opinion that a skin biopsy as indicated above carries
a high risk of causing a digital nerve injury leading to a neuroma causing
chronic pain which may require reconstructive surgery. My recommendation
is therefore that if volar digital skin biopsies are required then it is
much safer to harvest these in the midline of the finger but patients
should be warned of the potential nerve injury and neuroma risk as
important nerves are only a few millimeters under the skin surface on
fingers.
Competing interests:
None declared
Competing interests: No competing interests
Evidence-based demyelination
Here we have a method of being certain of Demyelination in some
strange Neuropathies.
Many of the early symptoms are so often passed over by the Primary
Doctor until diagnosis is made far too late by the senior Pundits for any
worthwhile treatment to be effective.
There is far too much of "Let's see how it goes, eh?" and "Maybe it's
a trapped nerve?" and in periodic surges the symptoms come and go. There
would be no harm done there and then in getting up and giving the
necessary Vitamin B.12 or B.1 injection.
Demyelination may be the result of malabsorption of Vitamins or an
attack by a Virus. Whichever, early treatment is advised and indeed
mandatory.
Malabsorption today may occur because of the multiplicity of strong
drugs which patients are prescribed (iatrogenic disease). Anti-
convulsants we know prevent the absorption of Vitamin B.12, as does
alcohol.
Myelin is produced by Oligodendroglia in the brain and are not these
cells just those which become scarred with Amyloid in Alzheimer's Disease?
Perpipheral Neuropathy occurs significantly in Beri-beri and is
easily rectified by immediate injections of Vitamin B.1 whatever the
symptomatology is. Malbsorption is the main cause here.
In Herpes Zoster the latent virus of Varicella causes the
Demyelination that results in the pain. If the myelin is not restored
then the pain remains as Post Herpetic Neuralgia for life. The nerve
fibres at post-mortem are found to be free of Myelin.
It is negligent and indeed criminal not to give B.12 injections in
all cases of Herpes Zoster.
The first successful use of Vitamin B.12 in the treatment of Herpes
Zoster was in a German Prisoner of War camp in 1944 using Liver Extract
(BMJ 15 June 1946). Since then it has been used equally successfully in
more refined presentations, but must be given within the first three weeks
to be effective.
One knows that Demyelination occurs in Multiple Sclerosis, Bell's
Palsy, Idiopathic Vertigo, Guillane-Barre Syndrome, Machiafalva-Bignani
Disease, Central Pontine Melinosis, Schilder's Disease, Neuromyelitis
Optica, Motor Neurone Diseas or Amyotrophic Lateral Sclerosis.
In most of these cases the diagnosis is long delayed until the Pundit
declares "You have XYZ disease. There is no cure and you can do nothing
about it! Do not take herbs. Do not waste your money. Do not take Chinese
medicine. It is progressive and you will die! Good Morning!"
It may well be that a virus is lurking as the cause of several or all
of those afore-mentioned syndromes?
With these Skin Biopsies one can have an early assurance that
demyelination is there ("evidence-based") and treatment with Vitamin B.12
can begin instantly if not before.
Herpes Zoster pain and signs can be relieved at once with daily
injections of 2,500 mcg. of Vitamin B.12 as in 1944. Folic Acid 5 mg. can
be added. In Bell's Palsy the facial paralysis is relieved quickly with
administration of Vitamin B.12. So with Idiopathic Vertigo.
It is time we came up to date.
Once it was claimed that Demyelination did not occur in Amyotrophic
Lateral Sclerosis. See then New England Journal of Medicine Vol: 355.
296 -304 of July 2006. The old man who died would have benefited from
much earlier admnistration of Vitamin B.12 and been diagnosed sooner than
at post-mortem with Drs. Lauria amd Lombardi's Skin biopsies.
Martindale's Pharmacopoeia: Vitamin B.12 plays a biochemical role in
the maintenance of Myelin in the nervous system. Deficienty results in
demyelination (Ovesen. DRUGS. 27. 148. 1984).
Competing interests:
None declared
Competing interests: No competing interests