Limited safety data are currently available for capsaicin 8% patch for diabetic neuropathy, which may have led the EMA to restrict use of this treatment to non-diabetic neuropathy patients.7 Treatment with capsaicin 8% patch did not result in changes suggestive of detrimental effects on sensory function in patients with painful diabetic neuropathy123 or painful HIV-AN12 at 12 weeks after treatment. Similarly, neurosensory testing in HIV-AN and PHN patients treated with up to four treatments over a period of 48 weeks revealed no evidence of impairment.124 The reversibility of both sensory function and ENF innervation after capsaicin 8% patch treatment has been documented in healthy subjects, with small reductions in tactile and sharp pain sensations returning to normal within 12 weeks and ENF density to within a few per cent of normal by 24 weeks.9 Because of the high selectivity of capsaicin for the TRPV1 receptor and the selective expression of TRPV1 in nociceptive sensory nerves, other skin sensory nerve endings may remain intact and functional even with pronounced defunctionalisation and reduction of cutaneous nociceptors.26 Capsaicin-insensitive nerve endings include those which arise from Aβ-fibres which transduce tactile and proprioceptive stimuli, as well as a subpopulation of C-fibres and the majority of Aδ-fibres, which are primarily responsible for mediating pin-prick.125 Non-TRPV1-expressing nerve fibres are also capable of transducing thermal stimuli, as they express TRP receptors such as TRPV2 (which is activated at 52C) and TRPV3 (which is activated at 39C).126 It should be remembered that ENF density measurements are a diagnostic tool, one of the several used to evaluate symptomatic small-fibre neuropathies. Age- and length-related reductions of ENF density occur in healthy individuals who display no symptoms of sensory loss.127 Therefore, perhaps it should not be surprising that the complex cutaneous innervation allows for selective defunctionalization of a subpopulation of cutaneous nociceptors (i.e. those capsaicin-sensitive) without significant loss of protective sensation. A recent study using topical capsaicin in an occlusive 48 h application reported elimination of immunostaining for both sensory and autonomic nerve markers.128 However, such cutaneous nerve fibre losses have not been observed with either the high-concentration patch8,9 or low-concentration creams.129
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