Evidence for the involvement of dopamine in ambulation promoted by menthol in mice

A Menthol-Enhanced "Cooling" Energy Gel Does Not Influence Laboratory Time Trial Performance in Trained Runners

l-menthol (menthol) is an organic compound derived from peppermint which imparts a refreshing mint flavor and aroma to oral hygiene products, chewing gum, and topical analgesics. Menthol has been identified as a non-thermal sensory cooling strategy for athletes when ingested or mouth-rinsed during exercise in hot environments. Therefore, sports nutrition products delivering a controlled concentration of menthol could be beneficial for athletes exercising in the heat. We sought to test the performance and perceptual outcomes of a novel menthol energy gel during treadmill running in the heat (33 °C, 49% RH). Fourteen trained runners (mean ± SD; age: 31 ± 6 years, VO2max: 56.5 ± 10.1 mL·kg-1·min-1, BMI: 23.2 ± 2.4 kg/m2; six female) participated in a randomized, crossover, double-blind, and placebo-controlled study. A menthol-enhanced energy gel (0.5% concentration; MEN) or flavor-matched placebo (PLA) was ingested 5 min before and again at 20 and 40 min of a 40 min treadmill exercise preload at 60% VO2max, followed by a 20 min self-paced time trial. The total distance, vertical distance, perceptual measures (thermal comfort, thermal sensation, rating of perceived exertion, and affect), and cognitive performance via computerized neurocognitive assessment were measured. No difference between 20 min self-paced time trial total distance (MEN: 4.22 ± 0.54 km, PLA: 4.22 ± 0.55 km, p = 0.867), vertical distance (MEN: 49.2 ± 24.6 m, PLA: 44.4 ± 11.4 m, p = 0.516), or any perceptual measures was observed (all p > 0.05). Cognitive performance was not different between the trials (all p > 0.05). These results suggest that a menthol energy gel is not superior to a non-menthol gel in terms of performance or perception during treadmill running in the heat. More research is needed to confirm whether these findings translate to ecologically valid settings, including outdoor exercise in ambient heat and during competition.

l-Menthol increases extracellular dopamine and c-Fos-like immunoreactivity in the dorsal striatum, and promotes ambulatory activity in mice

Similar to psychostimulants, the peripheral administration of menthol promotes mouse motor activity, and the neurotransmitter dopamine has been suggested to be involved in this effect. The present study aimed to elucidate the effects of l-menthol on parts of the central nervous system that are involved in motor effects. The subcutaneous administration of l-menthol significantly increased the number of c-Fos-like immunoreactive nuclei in the dorsal striatum of the mice, and motor activity was promoted. It also increased the extracellular dopamine level in the dorsal striatum of the mice. These observations indicated that after subcutaneous administration, l-menthol enhances dopamine-mediated neurotransmission, and activates neuronal activity in the dorsal striatum, thereby promoting motor activity in mice.

Pharmacological interventions for pediatric irritable bowel syndrome

INTRODUCTION

Irritable bowel syndrome is a common functional gastrointestinal disorder in children, characterized by recurrent abdominal pain associated with altered bowel habits in terms of both frequency and consistency. According to change in stool consistency it is categorized into 4 subtypes. From the etiological perspective, it is a combination of factors takes part in symptoms' generation, the overall treatment response rate is often unsatisfactory if a multidisciplinary is not pursued.

AREAS COVERED

The aim of this manuscript is to summarize the current pharmacotherapy in pediatric irritable bowel syndrome in order to aid clinicians in treating this challenging disorder.

EXPERT OPINION

Most evidence involving pediatric populations rely on open label or retrospective studies and/or are not specifically designed for irritable bowel syndrome but tend to generalize their results to mixed populations of children with functional gastrointestinal disorders. A high placebo response rate combined with poor patients' selection could account for the overall weak evidence supporting the use of pharmacological agents in pediatric irritable bowel syndrome. Given the multifaceted nature of the disorder, multidisciplinary approaches combining pharmacotherapy with alternative treatments is highly recommendable.

Identification of novel target molecules of l-menthol

The present study used a binding assay to identify novel target biomolecules of l-menthol ([−]-menthol) that promote mouse ambulation. Among 88 different ligands to specific biomolecules examined, 0.1 mM l-menthol inhibited the binding of 13 ligands with relatively high inhibition rates. The assays showed that l-menthol acts on calcium channels, sodium channels, γ-aminobutyric acid type A (GABA_A) receptor, GABA transporter, dopamine transporter, dopamine D4 receptor, adenosine A2a receptor, α2A-adrenergic receptor, histamine H2 receptor, bombesin receptor, angiotensin AT1 receptor, vasopressin V2 receptor, and leukotriene B4 receptor over a similar concentration range. The inhibition constant (K_i) for l-menthol inhibition of binding of [³H]-WIN35,428 to the human recombinant dopamine transporter was 6.15 × 10⁻⁴ mol/L. The K_i for l-menthol inhibition of binding of [³H]-ethynylbicycloorthobenzoate (EBOB), a ligand of GABA_A receptor picrotoxin site, was 2.88 × 10⁻⁴ mol/L. These results should aid future research by providing clues for investigating the mechanisms underlying l-menthol activities, including the ambulation-promoting effect. The present results suggest that the dopamine transporter, adenosine A2a receptor, dopamine D4 receptor, α2A-adrenergic receptor, and GABA_A receptor are promising candidate molecules that are involved in the mechanisms underlying the psychostimulant-like effect of l-menthol.

Herbal Therapies in Functional Gastrointestinal Disorders: A Narrative Review and Clinical Implication

The pathophysiology of functional gastrointestinal disorders (FGIDs) is still unclear and various complex mechanisms have been suggested to be involved. In many cases, improvement of symptoms and quality of life (QoL) in patients with FGIDs is difficult to achieve with the single-targeted treatments alone and clinical application of these treatments can be challenging owing to the side effects. Herbal preparations as complementary and alternative medicine can control multiple treatment targets of FGIDs simultaneously and relatively safely. To date, many herbal ingredients and combination preparations have been proposed across different countries and together with a variety of traditional medicine. Among the herbal therapies that are comparatively considered to have an evidence base are iberogast (STW-5) and peppermint oil, which have been mainly studied and used in Europe, and rikkunshito and motilitone (DA-9701), which are extracted from natural substances in traditional medicine, are the focus of this review. These herbal medications have multi-target pharmacology similar to the etiology of FGIDs, such as altered intestinal sensory and motor function, inflammation, neurohormonal abnormality, and have displayed comparable efficacy and safety in controlled trials. To achieve the treatment goal of refractory FGIDs, extensive and high quality studies on the pharmacological mechanisms and clinical effects of these herbal medications as well as efforts to develop new promising herbal compounds are required.

Menthol facilitates dopamine-releasing effect of nicotine in rat nucleus accumbens

Menthol is a significant flavoring additive in tobacco products. Accumulating clinical evidence suggests that menthol may promote tobacco smoking and nicotine dependence. Our previous studies demonstrated that menthol enhanced nicotine reinforcement in rats. However, it is unclear whether menthol interacts with nicotine at the neurochemical level. The present study used intracranial microdialysis to examine whether and the ways in which menthol affects nicotine-induced dopamine release in rats in the nucleus accumbens core (NAc), a terminal field of brain reward circuitry. To make comparisons with our previous work that showed an enhancing effect of menthol on nicotine self-administration behavior, male Sprague-Dawley rats were first trained in 20 daily 1-h sessions to press a lever for intravenous nicotine self-administration (15 μg/kg/infusion). Dopamine levels were then measured in the right NAc using intracranial microdialysis coupled with high-performance liquid chromatography. Five minutes before microdialysis, the rats received an intraperitoneal injection of menthol (0, 1, 2.5, and 5 mg/kg), a subcutaneous injection of nicotine (0.2 mg/kg or its vehicle), or both. Menthol alone did not affect dopamine levels in dialysates, whereas nicotine alone elevated dopamine levels. Combined nicotine and menthol administration significantly increased dopamine levels compared with nicotine alone. These data indicate a facilitating effect of menthol on nicotine-induced dopamine release in the NAc. These findings shed light on our understanding of the neurobiological mechanisms that underlie the menthol-induced enhancement of nicotine reinforcement.

Review article: the physiological effects and safety of peppermint oil and its efficacy in irritable bowel syndrome and other functional disorders

BACKGROUND

Peppermint oil has been used for centuries as a treatment for gastrointestinal ailments. It has been shown to have several effects on gastrointestinal physiology relevant to clinical care and management.

AIM

To review the literature on peppermint oil regarding its metabolism, effects on gastrointestinal physiology, clinical use and efficacy, and safety.

METHODS

We performed a PubMed literature search using the following terms individually or in combination: peppermint, peppermint oil, pharmacokinetics, menthol, oesophagus, stomach, small intestine, gallbladder, colon, transit, dyspepsia, nausea, abdominal pain, and irritable bowel syndrome. Full manuscripts evaluating peppermint oil that were published through 15 July 2017 were reviewed. When evaluating therapeutic indications, only randomised clinical trials were included. References from selected manuscripts were used if relevant.

RESULTS

It appears that peppermint oil may have several mechanisms of action including: smooth muscle relaxation (via calcium channel blockade or direct enteric nervous system effects); visceral sensitivity modulation (via transient receptor potential cation channels); anti-microbial effects; anti-inflammatory activity; modulation of psychosocial distress. Peppermint oil has been found to affect oesophageal, gastric, small bowel, gall-bladder, and colonic physiology. It has been used to facilitate completion of colonoscopy and endoscopic retrograde cholangiopancreatography. Placebo controlled studies support its use in irritable bowel syndrome, functional dyspepsia, childhood functional abdominal pain, and post-operative nausea. Few adverse effects have been reported in peppermint oil trials.

CONCLUSION

Peppermint oil is a natural product which affects physiology throughout the gastrointestinal tract, has been used successfully for several clinical disorders, and appears to have a good safety profile.

Effects of menthol and its interaction with nicotine-conditioned cue on nicotine-seeking behavior in rats

RATIONALE

Increasing clinical evidence suggests that menthol, a significant flavoring additive in tobacco products, may contribute to smoking and nicotine dependence. Relapse to smoking behavior presents a formidable challenge for the treatment of tobacco addiction. An unresolved issue is whether the mentholation of tobacco products precipitates relapse to tobacco use in abstinent smokers.

OBJECTIVES

The present study examined the effects of menthol on the perseverance and relapse of nicotine-seeking behavior in rats.

METHODS

Male Sprague-Dawley rats were trained to press a lever for intravenous nicotine self-administration (0.03 mg/kg/infusion) under a fixed-ratio five schedule of reinforcement. Each nicotine infusion was signaled by the presentation of a sensory stimulus that was established as a discrete nicotine-conditioned cue. Five minutes prior to the sessions, the rats received an intraperitoneal injection of menthol (0.1 mg/kg) or vehicle. In the subsequent extinction test sessions, nicotine was unavailable with or without menthol and/or the nicotine-conditioned cue. The reinstatement tests were performed the following day after the extinction criterion was met. Menthol was also tested on food-seeking responses. In a subset of nicotine-trained rats, a transient receptor potential melastatin 8 (TRPM8) antagonist RQ-00203078 was given prior to menthol administration.

RESULTS

Continued administration of menthol sustained responses on the previously active and nicotine-reinforced lever in the extinction tests. The readministration of menthol after extinction reinstated active lever responses. In both the extinction and the reinstatement tests, a combination of pre-session menthol administration and cue representation during the session produced a more robust behavioral effect than either menthol or the cue alone. No such effects of menthol was observed in food trained rats. RQ-00203078 did not change menthol effect on nicotine seeking.

CONCLUSION

These data demonstrated that menthol specifically sustained and reinstated nicotine-seeking behavior, and this effect was independent of TRPM8 activity. These findings suggest that menthol in most tobacco products, even not menthol labeled, may contribute to the perseverance of and relapse to tobacco-seeking behavior.

Enhancing effect of menthol on nicotine self-administration in rats

RATIONALE

Tobacco smoking is a leading preventable cause of premature death in the USA. Menthol is a significant flavoring additive in tobacco products. Clinical evidence suggests that menthol may promote tobacco smoking and nicotine dependence. However, it is unclear whether menthol enhances the reinforcing actions of nicotine and thus facilitates nicotine consumption. This study employed a rat model of nicotine self-administration to examine the effects of menthol on nicotine-taking behavior.

METHODS

Male Sprague-Dawley rats were trained in daily 1-h sessions to press a lever for intravenous nicotine self-administration under a fixed-ratio 5 schedule of reinforcement. In separate groups, rats self-administered nicotine at four different doses (0.0075, 0.015, 0.03, and 0.06 mg/kg/infusion). Five minutes prior to the two test sessions, menthol (5 mg/kg) or its vehicle was administered intraperitoneally in all rats in a counterbalanced design within each group. In separate rats that self-administered 0.015 mg/kg/infusion nicotine, menthol dose-response function was determined. Menthol was also tested on food self-administration.

RESULTS

An inverted U-shaped nicotine dose-response curve was observed. Menthol pretreatment shifted the nicotine dose-response curve to the left. The facilitating effect of menthol on the self-administration of 0.015 mg/kg/infusion nicotine was dose-dependent, whereas it produced similar effects at doses above the threshold of 2.5 mg/kg. Menthol tended to suppress the self-administration of food pellets.

CONCLUSIONS

These data demonstrate that menthol enhances the reinforcing effects of nicotine, and the effect of menthol was specific to nicotine. The findings suggest that menthol directly facilitates nicotine consumption, thereby contributing to tobacco smoking.

Brain regions and monoaminergic neurotransmitters that are involved in mouse ambulatory activity promoted by bupropion

Bupropion (BUP), a substituted phenyl-ethylamine, has been utilized for the treatment of depression and for smoking cessation, however, one concern is that BUP may increase a risk of psychosis similar to other substituted phenyl-ethylamine amphetamine (AMPH) and methamphetamine (MetAMPH). BUP promotes ambulation in mice and causes behavioral sensitization on the ambulation-promoting effect when repeatedly administered as well as AMPH and MetAMPH. The present study aimed to elucidate brain regions and monoaminergic neurotransmitters that are involved in the ambulation-promoting effect of BUP. c-Fos-like immunoreactivity (c-Fos-IR) mapping in brain in combination with measuring ambulatory activity was conducted to determine brain region(s) that is involved in the ambulatory effect of BUP. Three kinds of statistical analyses for c-Fos-IR in 24 brain regions consistently showed that c-Fos-IR in the Caudate putamen (CPu) is positively correlated with the ambulatory response to BUP. In addition, multiple regression analysis indicated that the ambulatory response is a function of c-Fos-IR not only in the CPu but also in the lateral septum nucleus (LS), median raphe nucleus (MnR), lateral globus pallidus (LGP), medial globus pallidus (MGP), locus coeruleus (LC) and ventral hypothalamic nucleus (VMH). Effects of BUP on monoaminergic neurotransmitters in the CPu were examined using in vivo microdialysis method, as the pharmacological experiments indicated that monoaminergic neurotransmitters, dopamine (DA) in particular, mediate the ambulatory response to BUP. Response of DA in the CPu to BUP was parallel to the ambulatory response, showing that DA in the CPu is involved in the ambulatory response to BUP. The present study also suggests that other brain regions such as the LC, the origin nucleus of norepinephrine (NE) neurons, and another neurotransmitter NE may also play some roles for the ambulatory response to BUP, however, further studies are needed to elucidate the roles.

Not so Cool? Menthol's discovered actions on the nicotinic receptor and its implications for nicotine addiction

Nicotine cigarette smoke is a large public health burden worldwide, contributing to various types of disease. Anti-tobacco media campaigns and control programs have significantly reduced smoking in the United States, yet trends for menthol cigarette smoking have not been as promising. Menthol cigarette smoking is particularly prevalent among young adults and African Americans, with implications for long-term impacts on health care. Continuing high rates of menthol cigarette addiction call into question the role of menthol in nicotine addiction. To date, a biological basis for the high rate of addiction and relapse among menthol cigarette smokers has not been defined. Studies have demonstrated a role for menthol in the metabolism of nicotine in the body. More recent findings now reveal an interaction between menthol and the nicotinic acetylcholine (nACh) receptor in cells. This receptor is central to the actions of nicotine in the brain, and plays an important role in nicotine addiction. The newly discovered effect of menthol on nACh receptors may begin to explain the unique addictive properties of menthol cigarettes.

Unusual effects of nicotine as a psychostimulant on ambulatory activity in mice

The present study examined the effect of nicotine, alone and in combination with various drugs that act on the CNS, on ambulatory activity, a behavioral index for locomotion, in ICR (CD-1) strain mice. Nicotine at 0.25–2 mg/kg acutely reduced ambulatory activity of ICR mice. The effect of nicotine was similar to that of haloperidol and fluphenazine but distinct from that of bupropion and methylphenidate. ICR mice developed tolerance against the inhibitory effect of nicotine on ambulatory activity when nicotine was repeatedly administered. This effect was also distinct from bupropion and methylphenidate as they produced augmentation of their ambulation-stimulating effects in ICR mice. Nicotine reduced the ambulation-stimulating effects of bupropion and methylphenidate as well as haloperidol and fluphenazine. Taken together, nicotine exhibited unusual effects as a psychostimulant on ambulatory activity in ICR mice.

Anxiolytic-like effect of Carvacrol (5-isopropyl-2-methylphenol) in mice: involvement with GABAergic transmission

Carvacrol (5-isopropyl-2-methylphenol) is a monoterpenic phenol present in the essencial oil of many plants. It is the major component of the essential oil fraction of oregano and thyme. This work presents the behavioral effects of carvacrol in animal models of elevated plus maze (EPM), open field, Rotarod and barbiturate-induced sleeping time tests in mice. Carvacrol (CVC) was administered orally, in male mice, at single doses of 12.5; 25 and 50 mg/kg while diazepam 1 or 2 mg/kg was used as standard drug and flumazenil (2.5 mg/kg) was used to elucidate the possible anxiolytic mechanism of CVC on the plus maze test. The results showed that CVC, at three doses, had no effect on the spontaneous motor activity in the Rotarod test nor in the number of squares crossed in the open-field test. However, CVC decreased the number of groomings in the open-field test. In the plus maze test, CVC, at three doses significantly increased all the observed parameters in the EPM test and flumazenil was able to reverse the effects of diazepam and CVC. Therefore, CVC did not alter the sleep latency and sleeping time in the barbiturate-induced sleeping time test. These results show that CVC presents anxiolytic effects in the plus maze test which are not influenced by the locomotor activity in the open-field test.

Evidence for dopamine involvement in ambulation promoted by menthone in mice

The present study examines the mechanism that underlies the ability of menthone (MTN), a constituent of peppermint oil, to promote mouse ambulation. Since bupropion (BUP), a dopamine (DA) uptake inhibitor, promotes mouse ambulation, the effect of MTN combined with BUP on ambulation was investigated. The results showed that BUP with MTN produced an additive interaction on mouse ambulation. The effects of DA antagonists chlorpromazine, fluphenazine, haloperidol, SCH12679 and spiperone on the ability of MTN to promote ambulation were then examined. All of these antagonists attenuated the effects of MTN. Prior exposure to the tyrosine hydroxylase inhibitor alpha-methyl-p-tyrosine, which inhibits catecholamines synthesis, decreased subsequent sensitivity to the effect of MTN. These results suggest that DA is involved in the ability of MTN to promote ambulation in mice.

Central nervous system activity of acute administration of isopulegol in mice

Isopulegol is a monoterpene alcohol intermediate in the preparation of (-)-menthol and it is present in the essential oils of various plants. This work presents behavioral effects of isopulegol in animal models of open field, elevated plus maze (EPM), rota rod, hole board, barbiturate-induced sleeping time, tail suspension and forced swimming tests in mice. Isopulegol was administered intraperitoneally to male mice at single doses of 25 and 50 mg/kg, while diazepam 1 or 2 mg/kg and imipramine 10 or 30 mg/kg were used as standard drugs. The results showed that, similar to diazepam (1 mg/kg), both doses of isopulegol significantly modified all the observed parameters in the EPM test, without alter the general motor activity in the open field test. In the same way, both doses of isopulegol increased the number of head dips in the hole-board test. Forced swimming and tail suspension tests showed that isopulegol (25 and 50 mg/kg) was able to induce a significant increase in the immobility time, in opposite to imipramine, a recognized antidepressant drug. There was a decrease in the sleep latency time and prolongation of the pentobarbital-induced sleeping time with both doses of Isopulegol. Different from diazepam (2 mg/kg), isopulegol (25 e 50 mg/kg) had no effect on the motor coordination of animals in the rota rod test. These results showed that isopulegol presented depressant- and anxiolytic-like effects.

Menthol and nicotine oppositely modulate body temperature in the rat

Menthol is a prominent additive in many tobacco products. To investigate possible interactions with nicotine, (-)-menthol (200 or 400 mg/kg) and (-)-nicotine (0.5 mg/kg) were injected subcutaneously in rats, and body temperature, which is modulated by brain nicotinic acetylcholine receptors, was measured. Nicotine caused robust (-1.6 degrees C) hypothermia, the magnitude and time course of which was not altered by menthol pretreatment. Menthol alone produced mild (0.4-0.8 degrees C) hyperthermia, which was not secondary to locomotor activation. Nicotine and menthol influence body temperature independently and oppositely; menthol does not appear to influence the function of the central nicotinic receptors that control body temperature.

Anticonflict effects of lavender oil and identification of its active constituents

The pharmacological effects of lavender oil were investigated using two conflict tests in ICR mice, and then the active constituents were identified. Lavender oil produced significant anticonflict effects at 800 and 1600 mg/kg in the Geller conflict test and at 800 mg/kg in the Vogel conflict test, suggesting that the oil has an anti-anxiety effect. Analysis using GC/MS revealed that lavender oil contains 26 constituents, among which alpha-pinene (ratio, 0.22%), camphene (0.06%), beta-myrcene (5.33%), p-cymene (0.3%), limonene (1.06%), cineol (0.51%), linalool (26.12%), borneol (1.21%), terpinene-4-ol (4.64%), linalyl acetate (26.32%), geranyl acetate (2.14%) and caryophyllene (7.55%) were identified. We examined the effects of linalool, linalyl acetate, borneol, camphene, cineol, terpinen-4-ol, alpha-pinene and beta-myrcene using the Geller and Vogel conflict tests in ICR mice. Cineol, terpinen-4-ol, alpha-pinene and beta-myrcene did not produce any significant anticonflict effects in the Geller test. Linalyl acetate did not produce any significant anticonflict effects in either test. Both borneol and camphene at 800 mg/kg produced significant anticonflict effects in the Geller, but not in the Vogel conflict test. Linalool, a major constituent of lavender oil, produced significant anticonflict effects at 600 and 400 mg/kg in the Geller and Vogel tests, respectively, findings that were similar to those of lavender oil. Thus, we concluded that linalool is the major pharmacologically active constituent involved in the anti-anxiety effect of lavender oil.

The Elucidation of the Mechanism of Weight Gain and Glucose Tolerance Abnormalities Induced by Chlorpromazine

Antipsychotic drugs induce weight gain and metabolic abnormalities. Recently, the role of adipocytokines secreted from adipocytes in the development of metabolic syndrome has received attention. The aim of this study was to investigate the effects of chlorpromazine (Cp) on body weight, glucose, lipid metabolism, and adipocytokine secretion in rats fed sucrose. Wistar rats received 15% sucrose (Suc group), 15% sucrose and Cp at 7.5 mg/kg per day (Suc + Cp group), or Cp alone (Cp group) in water for 10 weeks. Fasting glucose levels in the Suc and Suc + Cp groups were significantly higher than in the control (Cont) group. Fasting insulin levels in the Suc, Suc + Cp, and Cp groups were also significantly higher than in the Cont group. The adiponectin level in the Suc group was significantly higher than in the Cont group, although the adiponectin level in the Suc + Cp group was not. Furthermore, the plasma tumor necrosis factor (TNF)-alpha level in the Suc + Cp group was significantly higher than in the Suc group. These data suggest that Cp inhibits the compensatory response of adiponectin with respect to obesity due to increased expression of plasma TNF-alpha level. Cp may exert more harmful effects on the glucose level and insulin resistance than on other factors, which may be one of the mechanisms responsible for the metabolic syndrome induced by antipsychotic agents.

Menthol facilitates the skin analgesic effect of tetracaine gel

The aim of this study is to observe the effect of menthol on the percutaneous penetration and skin analgesic action of tetracaine gel (T-gel). Anesthetic gels containing 4% tetracaine in carbomer vehicle with and without menthol were prepared. The menthol penetration-enhanced gel conferred significantly higher diffusion of tetracaine across full-thickness mouse skin than non-penetration-enhanced gel, in a dose-dependent manner. The inter-cellular spaces of the stratum corneum in skin treated with menthol penetration-enhanced gel became extended as compared with those in non-penetration-enhanced gel. This may suggest that menthol's action was related to the changes of the epidermis ultra structures. An enlarged inter-cellular space, per se, would allow a better passage to tetracaine. To determine the efficacy of menthol penetration-enhanced tetracaine gel in the management of pain, a double-blind, placebo-controlled, randomized controlled trial (RCT) design was used. The mean verbal pain scores (VPS) were significantly lower in volunteers treated with penetration-enhanced tetracaine gel than those in volunteers receiving non-penetration-enhanced tetracaine gel or placebo. Menthol improved the analgesic efficacy of the tetracaine 4% gel in part through enhanced percutaneous permeation.