What are the best treatments for peripheral neuropathy?

1. Why Treating the Cause Changes Everything — and When Symptom Control Is the Focus

Clinical guidance across sources insists that treating the underlying disease (for example, improving glycemic control in diabetic neuropathy or stopping toxic exposures) is the primary determinant of long‑term outcome. Stanford and Mayo Clinic–style syntheses spell out that correcting deficiencies, removing offending drugs or toxins, and controlling metabolic drivers can slow or halt progression and sometimes improve nerve function ^{[4] [1]}. When nerve damage is established, the immediate clinical priority shifts to symptom control for pain, numbness, and functional impairment, with pharmacologic and device‑based options used to reduce suffering while rehabilitation and preventive measures limit complications like foot ulcers and falls ^{[1] [5]}. These sources date from 2019 through 2025 and collectively stress the dual strategy of cure when possible and symptom management when not ^{[4] [5]}.

2. Pharmacologic Frontline: Which Drugs Recur in Recommendations and Why

Multiple analyses identify gabapentin, pregabalin, and duloxetine as common first‑line agents for neuropathic pain, with lidocaine topical patches and capsaicin also used for localized symptoms. Drugs.com and institutional pages list these agents as frequently recommended, noting variability in individual response and side‑effect profiles; no single drug is universally superior, so clinicians often trial one agent and switch if needed ^{[2] [6]}. The Foundation for Peripheral Neuropathy summary also includes opioids and other adjuvants for refractory pain, but contemporary guidance increasingly cautions about long‑term opioid risks and favors gabapentinoids or SNRIs when feasible ^[7]. These medication recommendations are consistent across sources, but their selection must account for comorbidities, interactions, and patient preferences ^{[2] [6]}.

3. Devices, Procedures and Rehabilitation: When to Escalate Beyond Pills

Guidance collated from clinical sources highlights a range of procedural and rehabilitative options for difficult‑to‑control neuropathic pain: scrambler therapy, spinal cord stimulation, TENS, and physical therapy are cited as reasonable escalations after or alongside medications ^{[1] [7]}. Stanford and Mayo Clinic–style references present physical therapy and regular foot care as essential to preserving mobility and preventing complications, while specialty centers report neuromodulation techniques for refractory cases ^{[4] [1]}. Device and interventional therapies carry higher cost and variable evidence; they are typically reserved for patients who fail or cannot tolerate first‑line pharmacologic treatment, and their availability and insurance coverage affect real‑world use ^{[1] [7]}.

4. Supplements, Complementary Therapies and the Evidence Gap

Multiple sources mention alpha‑lipoic acid, B vitamins, acupuncture, and herbal/natural remedies as adjuncts with mixed evidence: some clinical reviews and patient resources report symptomatic benefit for certain patients, while systematic trial data are limited or inconsistent ^{[1] [8] [9]}. Nutritional correction is uncontroversial when a deficiency is documented—treating vitamin B12 deficiency or stopping alcohol is standard care—but routine use of nutraceuticals for all patients lacks robust, consistent randomized‑trial support ^{[4] [3]}. These sources caution clinicians to evaluate interactions and quality of supplements and to consider complementary therapies as supportive rather than replacements for established medical treatments ^{[3] [9]}.

5. Putting It Together: A Practical, Evidence‑Oriented Roadmap for Clinicians and Patients

Across the collected analyses, the practical approach is clear: identify and treat reversible causes; use guideline‑recommended drugs (gabapentin, pregabalin, duloxetine, topical agents) for neuropathic pain; add physical therapy, foot care, and lifestyle measures; reserve interventional or neuromodulation therapies for refractory cases; and consider supplements or acupuncture as adjuncts ^{[4] [2] [1]}. The sources range from 2019 to 2025 and reflect a consistent, multidisciplinary model of care that balances symptom relief, risk mitigation, and addressing root causes ^{[4] [5]}. Patients should expect individualized trials of therapy, close monitoring for side effects, and coordination among primary care, neurology, pain specialists, and rehabilitation professionals to optimize outcomes ^{[6] [7]}.