Topical menthol increases cutaneous blood flow

Menthol, the active ingredient in several topically applied analgesics, activates transient receptor potential melastatin 8 (TRPM8) receptors on sensory nerves and on the vasculature inducing a cooling sensation on the skin. Ilex paraguariensis is also a common ingredient in topical analgesics that has potential vasoactive properties and may alter the mechanisms of action of menthol. We sought to characterize the microvascular effects of topical menthol and ilex application and to determine the mechanism(s) through which these compounds may independently and combined alter cutaneous blood flow. We hypothesized that menthol would induce vasoconstriction and that ilex would not alter skin blood flow (SkBF). Three separate protocols were conducted to examine menthol and ilex-mediated changes in SkBF. In protocol 1, placebo, 4% menthol, 0.7% ilex, and combination menthol+ilex gels were applied separately to the skin and red cell flux was continuously measured utilizing laser speckle contrast imaging (LSCI). In protocol 2, seven concentrations of menthol gel (0.04%, 0.4%, 1%, 2%, 4%, 7%, 8%) were applied to the skin to model the dose-response curve. In protocol 3, placebo, menthol, ilex, and menthol+ilex gels were applied to skin under local thermal control (34°C) both with and without sensory nerve blockage (topical lidocaine 4%). Post-occlusive reactive hyperemia (PORH) and local heating (42°C) protocols were conducted to determine the relative contribution of endothelium derived hyperpolarizing factors (EDHFs)/sensory nerves and nitric oxide (NO), respectively. Red cell flux was normalized to mean arterial pressure expressed as cutaneous vascular conductance (CVC: flux·mmHg(-1)) in all protocols. Topical menthol application increased SkBF compared to placebo (3.41±0.33 vs 1.1±0.19CVC: p<0.001). During the dose-response, SkBF increased with increasing doses of menthol (main effect, p<0.05) with an ED50 of 1.0%. Similarly, SkBF was increased after menthol application during PORH (3.62±0.29 vs. 2.50±0.21flux·mmHg(-1); p<0.001), but not local heating (2.98±0.24 vs 2.86±0.32flux·mmHg(-1); p=0.44). Concurrent sensory nerve inhibition attenuated menthol-mediated vasodilation at thermoneutral baseline (1.29±0.19flux·mmHg(-1); p<0.001) and during PORH (2.79±0.28flux·mmHg(-1); p<0.001), but not during local heating (3.45±0.21flux·mmHg(-1); p=0.1). Topically applied menthol, but not ilex, dose-dependently increases blood flow in the cutaneous microvasculature. This increase in blood flow is mediated, in-part by sensory nerves and EDHFs.