Intraepidermal Nerve Fiber Quantification of the Mouse Hind Paw Footpads: A Detailed and Simplified Protocol

Small fiber neuropathy (SFN) is an underdiagnosed condition characterized by sensory and autonomic dysfunction due to impairment of small nerve fibers in skin, blood vessels, and internal organs. Various underlying disorders are associated with SFN, and the pathophysiology of nerve fiber damage and functional impairment is the subject of extensive research. Diagnosis of SFN is challenging as standard electrodiagnostic techniques assess large fiber function and therefore are normal in SFN patients. The current gold standard for SFN diagnosis in humans is a skin biopsy, commonly obtained from the distal leg, hairy skin region, with evaluation of intraepidermal nerve fiber density (IENFD) using protein gene product 9.5 (PGP9.5) immunolabeling. While well-established in clinical practice, equivalent standardized, reproducible methods for assessing IENFD in experimental mouse models are lacking, which limits translational research in this field. Previous work in mice has relied on diverse antibodies, variable tissue sampling, and the use of confocal microscopy to trace nerve fibers. Other approaches have used chromogenic precipitate-based staining, which limits the ability to co-label multiple proteins. Here, we present a detailed, simple, and reproducible protocol for IENFD quantification of small nerves in the distal glabrous skin of the mouse hind paw. This protocol uses the two distal footpads, ensuring consistent sampling across animals. Prior to sectioning, the tissue is fixed and cryoprotected. Serial 20-μm sections are mounted on glass slides, dried, permeabilized, blocked, and immunostained with an anti-PGP9.5 monoclonal antibody, and then detected by binding secondary fluorescent-labeled antibodies. Although murine hairy skin analysis may apparently show a higher translational value, as it better reflects human biopsy sites, it is compromised by dense hair shafts and follicles, which interrupt epidermis continuity and thus interfere with sampling consistency. Polyneuropathy sensory symptoms, in fact, begin at the most distal sensory site, which is the glabrous skin of the toes. Thus, evaluation of this anatomical location best represents the clinical realm and may have the best sensitivity for identifying early axonal changes. In this protocol, we focused on IENFD quantification as done in human samples. Mechanoreceptors such as Meissner corpuscles are detectable and quantifiable by this method, and represent additional value since pressure-evoked pain, transmitted by these, is often reported by affected individuals. This immunolabeling protocol can be completed within one day [involving a small number of animals, where all three stages can be performed during a long working day (approximately 12 h)], while the entire workflow, including fixation and cryoprotection, is completed in up to 72 h. Importantly, the dermal and epidermal small fibers can be visualized using a standard fluorescence microscope, thereby avoiding the need for confocal imaging while maintaining high reproducibility. Preliminary validation in several animal models of inflammatory neuropathy and pain demonstrated a reproducible approximately 50% reduction in IENFD compared to controls, reaching statistical significance with n = 4 per group. This method supports SFN research and preclinical evaluation of novel therapeutics. Key features • Immunostaining protocol for visualizing small epidermal nerve fibers in mouse hind paw footpads. • Use of PGP9.5 labeling, with a monoclonal antibody that is used for human diagnostics, enabling translational comparability between mouse models and clinical studies. • Fluorescence microscopy analysis, without dependence on confocal imaging. • A rapid (12-72 h) and reproducible workflow for skin processing and intraepidermal nerve fiber quantification.