Epidermal nerve fiber density assessment: probably not worth doing in-house

About a month ago, I addressed the issue of skin biopsies for patients with peripheral neuropathy to assess for nerve fiber density. Since that post, I have heard that this test is not something to be taken lightly. Dr. Tom Smith (pictured) of the University of Massachusetts had this to say about the test: "Basically, to assess fiber density correctly in these skin biopsies, you need a considerable investment in technology (e.g. a confocal microscope, morphometric software program, etc) and technician training -- do you really have time to sit and count fibers?" Dr. Smith went on to say that in his opinion, there is a rather high initial investment for a relatively small volume of cases. Since a few university labs and Therapath already offer this service, its probably wise for most institutions of small or medium size to outsource this particular test. Finally, might these skin biopsies ultimately turn out to be a fad? Do these biopsies really provide useful information beyond what one could gain from clinical and electrophysiologic exam? Given these concerns, I'll likely recommend Therapath to any clinician looking for an epidermal nerve fiber density assessment.