Overview
Peripheral neuropathy is damage to the peripheral nerves outside the brain and spinal cord. It causes numbness, tingling, pain, and weakness, typically starting in the feet and hands. Diabetes is the most common cause in the UK. It can affect sensory, motor, or autonomic nerves, or a combination. Some causes are reversible if the underlying condition is treated.
How common is it?
Peripheral neuropathy affects approximately 2.4% of the general population, rising to 8% in older adults. Diabetic peripheral neuropathy affects about 50% of people with long-standing diabetes.
Causes and risk factors
Peripheral nerves are damaged by metabolic, toxic, immune-mediated, or hereditary mechanisms.
Common risk factors
- Diabetes mellitus (most common acquired cause globally)
- Alcohol excess
- Vitamin B12 deficiency
- Hypothyroidism
- Chronic kidney disease
- Medication: chemotherapy (platinum, vincristine, taxanes), isoniazid, metronidazole, statins (rare)
- Autoimmune: Guillain-Barre syndrome, CIDP, vasculitis, Sjogren syndrome
- Infections: HIV, hepatitis C, Lyme disease, leprosy
- Hereditary: Charcot-Marie-Tooth disease
- Paraneoplastic (underlying cancer)
- Idiopathic (no cause found in 30%)
Symptoms
- Numbness and reduced sensation, particularly in feet and hands (glove and stocking distribution)
- Burning, stabbing, or electric-shock pain
- Tingling and pins and needles
- Sensitivity to light touch (allodynia)
- Weakness and muscle wasting (motor neuropathy)
- Loss of balance and coordination (sensory ataxia)
- Autonomic: postural hypotension, sweating abnormalities, bowel/bladder dysfunction
When to see a doctor
Seek urgent neurology review for rapidly progressive weakness, which may indicate Guillain-Barre syndrome (a medical emergency). See a GP for persistent tingling, numbness, or burning in the feet.
Diagnosis
Nerve conduction studies (NCS) and electromyography (EMG) characterise the type (axonal vs demyelinating) and severity. Blood tests: HbA1c, B12, folate, TFTs, renal and liver function, immunoglobulins, serum protein electrophoresis, vasculitis screen, HIV. Nerve biopsy for selected complex cases.
Treatments
Treatment of underlying cause
Optimal glycaemic control prevents and may slow diabetic neuropathy progression. B12 replacement for deficiency. Alcohol abstinence. Immunotherapy (IVIg, plasma exchange, steroids) for immune-mediated neuropathies.
Neuropathic pain management
First-line: duloxetine or pregabalin/gabapentin. Second-line: amitriptyline (cost-effective, sedating). Topical capsaicin 8% patch or lidocaine for localised neuropathic pain. Tramadol short-term for breakthrough pain.
Foot care in diabetic neuropathy
Annual foot inspection, specialised footwear, prompt treatment of ulcers, and avoidance of bare-foot walking are essential to prevent Charcot arthropathy and amputation.
Self-care and lifestyle
- Inspect feet daily if sensory neuropathy is present
- Wear properly fitting shoes and avoid going barefoot
- Control blood glucose as tightly as tolerated
- Avoid alcohol completely if alcohol-related neuropathy
Prevention
Optimal glycaemic control from early in diabetes reduces neuropathy incidence by 60 to 70%. Avoiding alcohol excess and vitamin B12 deficiency (supplementation needed in vegans and those on long-term metformin) are preventive.