To evaluate the loss of autonomic nerve fibers in patients with clinical pure small-fiber sensory neuropathy, we performed skin punch biopsies in 17 and 15 age- and sex-matched controls. Biopsies were taken 10 cm above the lateral malleolus, and 5-mum sections were stained with hematoxylin and eosin and the panaxonal marker protein gene product (PGP) 9.5. Positively stained fibers, represented as dots, innervating the erector pili muscles, arterioles, and sweat glands (SG) were counted. The ratios between the number of nerve fibers and nuclei of each structure were calculated. The autonomic innervation was significantly reduced in the patients' group compared with controls in all the examined autonomic-innervated structures: SG (0.27 +/- 0.15 vs. 0.66 +/- 0.37, p = 0.001), arterioles (0.38 +/- 0.32 vs. 0.86 +/- 0.45, p=0.002), and the erector pili muscle (0.58 +/- 0.27 vs. 1.23 +/- 0.87, p = 0.036). Our results suggest that autonomic involvement occurs in patients with sensory small-fiber neuropathy and that punch skin biopsy using thin sections is a simple and convenient method to detect these dermal autonomic small-fiber abnormalities.