Interpretation  Guide  to  

Eccrine   sweat   glands   are   innervated   by   long,   thinly   myelinated   and   unmyelinated   C   fibers   of   the   sympathetic  
nervous   system   that   are   prone   to   early   damage   in   many   neuropathic   processes,   including   dysautonomia.   Small  
fiber  neuropathy  (SFN)  may  be  the  first  manifestation  of  systemic  disease  and  can  predict  progression  to  a  more  
diffuse  neuropathy,  making  this  early  diagnosis  important  for  the  treatment  of  patients.    

SUDOSCAN  results  will  enable  you  to  perform  an  objective  assessment  of  small  and  peripheral  sympathetic  nerve  
fiber  function.  This  will  help  you  to  identify  the  etiology  of  the  disease,  keeping  in  mind  that  about  33%  of  small  
fiber  neuropathies  remain  idiopathic  despite  appropriate  diagnostic  evaluation.  Objective  evaluation  of  the  disease  
with   regular   interval   retesting   can   increase   patient   compliance   and   can  be  particularly   important     in   the   treatment  
of  neuropathic  pain,  if  present.    

The   results   of   SUDOSCAN   tests   are   provided   as   hand   and   foot   Electrochemical   Skin   Conductances   (ESC)   that  
indicate   sweat   dysfunction   and   are   a   marker   of   small   fiber   peripheral   neuropathy.   ESC   are   expressed   in  
microSiemens   (μS),   ranging   from   0   to   100.     In   general,   ESC   in   the   ‘green’   zone   are   healthy,   ESC   in   the   ‘yellow’   zone  
indicate  moderate  dysfunction,  and  ESC  in  the  ‘orange-­‐red’  zone  correspond  to  severe  dysfunction.    
 
The  two  main  points  to  consider  for  correct  interpretation  of  SUDOSCAN  results  are:    
§ Asymmetry.   If   greater   than   20%   it   suggests   damage   limited   to   a   single   side.     This   is   only   valid   when   the  
contralateral   ESC   scores   are   in   the   ‘green’   zone.     If   the   contralateral   ESC   is   itself   in   the   ‘yellow’   or   ‘red’  
zone,  then  bilateral  dysfunction  exists.  
§ Location  of  disturbances  (hands  or  feet)  to  evaluate  length  dependency  of  the  damage.    
 

In  the  diagnostic  strategy  the  following  questions  should  also  be  answered:    
§ What:  Are  there  other  signs  or  symptoms  of  autonomic  dysfunction?  Are  sensory  or  motor  nerves  (large  
fibers)  involved?      
§ When:  If  symptoms  are  present,  how  long  have  they  been  present  and  was  their  onset  acute  or  chronic?    
§ Context:   What   are   the   patient’s   medical   history,   current   or   past   medications,   family   history   (hereditary  
diseases)?  
 
 
 
 
 
 
 
 
 

Interpretation  guide  to  SUDOSCAN   1  

 
  

Causes  of  SUDOSCAN  disturbances    validated  by   Suggested  evaluation  

clinical  studies*  
1
Diabetes  or  glucose  intolerance     Fasting  glucose,  2-­‐hour  oral  glucose  tolerance  test ;  due  to  
high  rate  of  coexistance,  Vit  B12,  thyroid,  Vit  D,  and  lipid  
levels  should  also  be  measured  

Diabetic  peripheral  neuropathy   Clinical  neurological  examination,  other  assessments  

2
based  on  NE  exam  and  usual  diabetes  care  
3,4  
Diabetic  nephropathy     Medical  history,  renal  function  testing

Peripheral  and  cardiac  autonomic  neuropathy   Heart  rate  variability,  Ewing  tests,  appropriate  specialist  
5  
referral

Familial  Amyloid  Polyneuropathy   Medical  and  family  history,  genetic  testing,  appropriate  
6  
specialist  referral

Fabry  disease  (analysis  ongoing)                                                                                                                                                                                                                                                                                                                                                                          

*classified  according  to  frequency  of  occurrence;  potential  causes  are  not  mutually  exclusive  

Possible  causes  of  SUDOSCAN  disturbances,   Suggested  evaluation  

not  currently  validated  by  research      
8-­‐10  
Connective  tissue  diseases,  autoimmune   See  details  for  specific  diagnostic  testing  in  references
diseases,  hereditary  conditions  (Fabry,  HSAN,  
Tangier’s,  vasculitis)  

Hyperlipidemia   Fasting  lipid  panel  

Chronic  alcohol  abuse,  history  of  alcoholism   Medical  history,  clinical  examination,  liver  function  tests  

Pharmacological  toxins  (statins,  anti-­‐ Medical  history  including  current  and/or  past  medications  
retrovirals),  chemotherapy    

Environmental  Toxins,  Infections  (HIV,   Toxin  exposure  history,  specialized  toxicological  and  infectious  
8-­‐10  
Hepatitis  C,  Lyme  disease)   disease  studies

Hypothyroidism   Medical  history,  clinical  examination,  TSH  and  free  T4  levels  

 
Potential  unverified  causes  of  asymmetry  in     Suggested  evaluation  
SUDOSCAN  results  

Nerve  entrapment:    spinal  or  peripheral     Medical  history,  physical  and  neurological  examination,  
(carpal  tunnel,  tarsal  tunnel)   unilateral  extremity  weakness  

Peripheral  Artery  Disease  (PAD)   Ankle  brachial  index,  arterial  Duplex  ultrasound,  angiography  

Extremity  Trauma/Injury     Medical  history  (comminuted  fracture),  imaging  study  

Dorsal  root  ganglion,  sympathetic  ganglion   Neurological  examination,  appropriate  referral,  imaging  study  
chain  disease  

Complex  Regional  Sympathetic  Dystrophy   Medical  history,  physical  examination,  imaging  study  

Interpretation  guide  to  SUDOSCAN   2  

 
  

Effect  on  SUDOSCAN   Potential  confounding  factors  to   Examples  and  Comments  
SUDOSCAN  results,  not  fully  validated  
by  research  

ELEVATE  SUDOSCAN   Angiotensin-­‐converting  enzyme  (ACE)   May  falsely  elevate  SUDOSCAN  

SCORES   Inhibitors  and  angiotensin  II  receptor   scores  
blockers  (ARB)  

DECREASE  SUDOSCAN   Medications  with  anti-­‐cholinergic   Tricyclic  antidepressants,  

SCORES   effects     antihistamines,  antimuscarinics,  
anti-­‐Parkinson  agents,  ranitidine,  
11  
muscle  relaxants may  decrease  
 
ESC  

Beta-­‐blockers     Propranolol,  labetalol,  timolol  may  

decrease  ESC  scores  

Second  and  Third  degree  burns  (of   Medical  history,  clinical  

the  palms  or  soles),  palmoplantar   examination  
keratodermas  

Acute  Alcohol  Intake     Heavy  alcohol  ingestion  within  the  

last  24  hours  may  lower  ESC  
scores  

 
 
REFERENCES  
 
[1]    
Schwarz   P,   Brunswick   P,   Calvet   JH.   EZSCAN   a   new   tool   to   detect   diabetes   risk.   British   Journal   of   Diabetes   &  
Vascular  diseases.  2011;11(4):204-­‐9.  
[2]    
Casellini   CM,   Parson   HK,   Richardson   MS,   Nevoret   ML,   Vinik   AI.   Sudoscan,   a   Noninvasive   Tool   for   Detecting  
Diabetic  Small  Fiber  Neuropathy  and  Autonomic  Dysfunction.  Diabetes  Technol  Ther.  2013;15(11).  
[3]  
Ozaki   R,   Cheung   KK,   Wu   E,   Kong   A,   Yang   X,   Lau   E,   Brunswick   P,   Calvet   JH,   Deslypere   JP,   Chan   JCN.   A   new   tool   to  
detect   kidney   disease   in   Chinese   type   2   diabetes   patients—comparison   of   EZSCAN   with   standard   screening  
methods.  Diabetes  tech  &  ther.  2011;13(9):937-­‐43.  
[4]  
Freedman  BI,  Bowden  DW,  Smith  SC,  Xu  J,  Divers,  J.  Relationships  between  electrochemical  skin  conductance  
and  kidney  disease  in  type  2  diabetes.    In  Press.  
[5]  
Yajnik  CS,  Kantikar  V,  Pande  A,  Deslypere  JP,  Dupin  J,  Calvet  JH,  Bauduceau  B.  Screening  of  cardiovascular  
autonomic  neuropathy  in  patients  with  diabetes  using  non-­‐invasive  quick  and  simple  assessment  of  sudomotor  
function.  Diabetes  Metab.  2013  Apr;39(2):126-­‐31.    
[6]  
Adams  D,  Cauquil  C,  Mincheva  Z,  Theaudin  M,  Beaudonnet  G,  Labeyrie  C,  Depuydt  S,  Iliescu  I,  Lacroix  C,  Grisoni  
ML.    Sudomotor  function  assessment  by  SUDOSCAN  in  FAP  patients:    the  NNERF  experience.    Poster  
presentation.    Peripheral  Nerve  Society.    Saint-­‐Malo,  France,  June  2013.  
[8]  
Burns  TM,  Mauermann  ML.  The  evaluation  of  polyneuropathies.  Neurology.  2011  Feb  15;76(7  Suppl  2):S6-­‐13.  
[9]  
Freeman  R.  Autonomic  peripheral  neuropathy.  Lancet  2005;365:1259-­‐1270.  
[10]  
Tavee  J,  Zhou  L.  Small  fiber  neuropathy:  a  burning  problem.  Cleve  Clin  J  Med.  2009  May;76(5):297-­‐305.  
[11]  
Pharmacist’s  Letter/Prescriber’s  Letter  –  Document  #271206.    Therapeutic  Research  Center.  December  2011.  
Available  at  www.pharmacistletter.com.    

Interpretation  guide  to  SUDOSCAN   3  

 
  

Case  Studies  Illustrating  Various  Scenarios  of    

Abnormal  SUDOSCAN  results  
 
  Peripheral  autonomic  
Case  1   and  small  fiber  
  dysfunction  
 
Background  
33   year-­‐old   African   American   female,   BMI   32,   consults   her   primary   care   physician   for   burning   in   her   feet   in   the  
evening  after  working  at  the  pizza  parlor  all  day.      
 

SUDOSCAN  report  
 
 
> Feet  Mean  ESC:    26  μS,  10%  asymmetry  
> Hands  Mean  ESC:    72  μS,  1%  asymmetry  
 
 
 

 
 
Discussion  
Results  are  suggestive  of  a  peripheral  autonomic  and  small  fiber  dysfunction.    From  the  brief  history,  the  most  likely  
clinical  suspicion  should  be  dysglycemia,  whether  metabolic  syndrome,  impaired  glucose  tolerance,  or  diabetes.    An  
appropriate   work-­‐up   and   intervention   should   be   conducted;   SUDOSCAN   should   be   repeated   in   3   months   or   as  
medically   necessary   after   treatment   is   instituted.     If   low   feet   scores   persist,   consider   screening   for   cardiac  
autonomic  neuropathy  risk.  
 

Interpretation  guide  to  SUDOSCAN   4  

 
  

  Effect  of    
Case  2  
  alcohol  
 
Background  
55  year-­‐old  Caucasian  male  with  past  medical  history  of  mild  hypertension,  BMI  29;  he  is  asymptomatic.    
 

SUDOSCAN  report  
At  t=0  
   
 
> Feet  Mean  ESC:  38  μS,  19%  asymmetry  
> Hands  Mean  ESC:  56  μS,  5%  asymmetry    
 
 
 
 
 
After  48  hours  
 
 
> Feet  Mean  ESC:  87  μS,  3%  asymmetry  
> Hands  Mean  ESC:  88  μS,  0%  asymmetry    
 

 
 
 
Discussion  
The  patient  was  a  physician  attending  a  medical  conference  and  was  scanned  following  ingestion  of  a  large  amount  
of   alcohol   earlier   in   the   day.     He   was   obviously   impaired   at   time   of   testing.     Alcohol   may   result   in   a   chronic  
neuropathy,   but   may   also   impair   SUDOSCAN   scores   following   moderate   consumption.     Repeat   testing   after   48  
hours  of  sobriety  showed  completely  normal  SUDOSCAN  results.  
 
 
 
 
 
 
 
 
 

Interpretation  guide  to  SUDOSCAN   5  

 
  

 
Effect  of  
Case  3  
  medication  
 
Background  
55   year-­‐old   female   treated   with   amitriptyline   for   depression   with   insomnia.     No   other   significant   past   medical  
history.      
 

SUDOSCAN  report  
 
§ SUDOSCAN  score  while  on  amitriptyline  
 
       
> Feet  ESC  8  μS,  Hands  ESC  22  μS  
 
 
 
 
 
 
§ SUDOSCAN  report  24  hours  after  stopping  amitriptyline  
 
 
                                                       
>      Feet  ESC  38  μS  ,  Hands  ESC  56  μS  
     
 
 
 
 
§ SUDOSCAN  report  48  hours  after  stopping  amitiriptyline  
 
 
 
> Feet  ESC  60  μS  ,  Hands  ESC  46  μS  
 

 
 
Discussion  
Amitriptyline,   a   tricyclic   antidepressant,   has   significant   anti-­‐cholinergic   effects.     This   is   most   likely   the   reason   for  
this   patient’s   dramatically   low   ESC   scores,   considering   she   has   no   known   neuropathy   and   sympathetic   nerve  
endings   on   sweat   glands   predominantly   release   acetylcholine   as   a   neurotransmitter.     ESC   scores   eventually  
returned  to  normal  after  removal  of  amitryptiline.  

Interpretation  guide  to  SUDOSCAN   6  

 
  

  Effect  of  ethnicity  and  

Case  4   nerve  entrapment  
 

 
Background  
45  year-­‐old  right-­‐handed  African  American  female  with  tingling  and  numbness  in  her  right  hand.    Diagnosed  2  years  
ago   with   Type   2   DM;   treated   with   Metformin   BID   with   HbA1c   stable   at   7.0%;   BMI   30.     She   is   employed   as   a  
receptionist/administrative  assistant  at  your  colleague’s  family  practice  clinic.      
 

SUDOSCAN  report  
 
 
> Feet  Mean  ESC  69  μS,  0%  asymmetry  
> Hands  Mean  ESC  63  μS,  29%  asymmetry  
> Left  hand  ESC  is  73  μS  and  right  hand  ESC  is  52  μS  
 
 
 
 

Discussion  
Several   factors   may   be   contributing   to   a   peripheral   autonomic   neuropathy   in   this   patient.     Being   African   American,  
her  scores  may  be  normal  though  lower  than  a  similar  Caucasian  patient.    On  this  scan,  her  feet  scores  appear  in  
the  green  zone  and  are  considered  normal  for  her  racial  background.    This  is  reassuring  in  a  diabetic  patient  with  
reasonable  control  of  her  diabetes.    Losing  some  weight  may  help  improve  this  score  further.  
Her  hand  symptoms  and  SUDOSCAN  suggest  RIGHT  hand  dysfunction;  clinical  neurological  examination  will  most  
likely   expose   a   carpal   tunnel   syndrome,   which   is   more   common   among   diabetics   than   the   general   population.    
Appropriate   treatment   should   be   instituted   and   a   follow-­‐up   SUDOSCAN   may   be   used   to   follow   therapeutic  
effectiveness.  
 

Interpretation  guide  to  SUDOSCAN   7