344 DIABETES CARE, VOLUME 24, NUMBER 2, FEBRUARY 2001

F
unctional abnormalities of the micro-
circulation have gained significant
attention in recent years for their
potential pathogenic role in the develop-
ment of diabetic complications, particularly
diabetic neuropathy and diabetic foot prob-
lems (15). The microvascular tone is reg-
ulated by several humoral and neural fac-
tors. The vascular endothelium has an
important role in controlling the microvas-
cular tone by releasing several vasodilator
substances such as nitric oxide, prostacyclin
and endothelium-derived hyperpolarizing
factor, and vasoconstrictor substances such
as prostaglandins and endothelin (6). Nitric
oxide is the most important vasodilator
substance responsible for endothelium-
dependent vasodilation. After its secretion
from the endothelium, it diffuses to the
adjacent smooth muscle cells and stimu-
lates the guanylate cyclase enzyme to pro-
duce cyclic guanosine 3,5-monophos-
phate, which, in turn, leads to smooth
muscle relaxation and vasodilation (7).
The normal neurovascular response
conducted through the C nociceptive nerve
fibers is another important mechanism for
the regulation of the microcirculation.
Stimulation of the C nociceptive nerve
fibers leads to antidromic stimulation of the
adjacent C fibers, which secrete vasodilat-
ing substances such as substance P and
bradykinin, causing vasodilation at the
injured or inflamed skin areas. This vasodi-
lating response, also known as the Lewis
triple-flare response, is decreased in the
presence of diabetic neuropathy. Reduction
of local blood flow increases the vulnera-
bility of the neuropathic limb to severe dia-
betic foot problems (8,9). It has been
postulated that the abnormality in the neu-
rovascular response in the neuropathic
limb further aggravates the abnormalities in
the microcirculation, and a vicious cycle
may ensue (10).
Several recent studies (1013) have
demonstrated reduced endothelium-
dependent vasodilation in patients with
either type 1 or type 2 diabetes. However,
little information is available regarding the
contribution of nerve-axon reflex-related
vasodilatation to maximal skin vasodila-
tion in such patients (8,9). The recent
development of noninvasive techniques
that can reliably quantify blood flow in the
skin microcirculation has made it possible
to study changes in microvascular function
in patients with diabetes (14,15). In the
present study, we have examined the con-
tributing role of the nerve-axon reflex-
related vasodilation response to the total
skin vasodilation at both the forearm and
From the Clinical Research Center (O.H., K.A.-E., E.S.H.), Joslin Diabetes Center, Department of Medicine,
and the JoslinBeth Israel Deaconess Foot Center and Microcirculation Laboratory (F.W.L., A.V.), Department
of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Address correspondence and reprint requests to Aristidis Veves, MD, Microcirculation Laboratory, Palmer
317, West Campus, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215. E-mail:
aveves@caregroup.harvard.edu.
Received for publication 6 July 2000 and accepted in revised form 19 October 2000.
Abbreviations: CV, coefficient of variation.
A table elsewhere in this issue shows conventional and Systme International (SI) units and conversion
factors for many substances.
Contribution of Nerve-Axon
Reflex-Related Vasodilation to the Total
Skin Vasodilation in Diabetic Patients
With and Without Neuropathy
O R I G I N A L A R T I C L E
OBJECTIVE To examine the contribution of nerve-axon reflex-related vasodilation to
total acetylcholine-induced vasodilation in the skin of normal and diabetic subjects.
RESEARCH DESIGN AND METHODS The skin microcirculation was evaluated at
the forearm level in 69 healthy subjects and 42 nonneuropathic diabetic patients and at the foot
level in 27 healthy subjects and 101 diabetic patients (33 with neuropathy, 23 with Charcot
arthropathy, 32 with peripheral vascular disease and neuropathy, and 13 without complications).
Two single-point laser probes were used to measure total and neurovascular vasodilation
response to the iontophoresis of 1% acetylcholine, 1% sodium nitroprusside, and deionized water.
RESULTS The neurovascular response to acetylcholine was significantly higher than the
response to sodium nitroprusside and deionized water (P 0.01). At the forearm level, the
contribution of neurovascular response to the total response to acetylcholine was 35% in dia-
betic patients and 31% in control subjects. At the foot level, the contribution was 29% in dia-
betic patients without neuropathy and 36% in control subjects, while it was significantly
diminished in the three neuropathic groups. A significantly lower nonspecific nerve-
axonrelated vasodilation was observed during the iontophoresis of sodium nitroprusside,
which does not specifically stimulate the C nociceptive fibers.
CONCLUSIONS Neurovascular vasodilation accounts for approximately one-third of the
total acetylcholine-induced vasodilation at both the forearm and foot levels. The presence of
diabetic neuropathy results in reduction of both the total vasodilatory response to acetylcholine
and the percentage contribution of neurovascular vasodilation to the total response. Acetyl-
choline and sodium nitroprusside cause vasodilation in the skin microcirculation through dif-
ferent pathways.
Diabetes Care 24:344349, 2001
OSAMA HAMDY, MD
KARIM ABOU-ELENIN, MD
FRANK W. LOGERFO, MD
EDWARD S. HORTON, MD
ARISTIDIS VEVES, MD
P a t h o p h y s i o l o g y / C o m p l i c a t i o n s
DIABETES CARE, VOLUME 24, NUMBER 2, FEBRUARY 2001 345
Hamdy and Associates
foot levels of neuropathic and nonneuro-
pathic diabetic patients.
RESEARCH DESIGN AND
METHODS
Patients
We studied the skin microcirculation at the
forearm level in 69 healthy subjects and 42
nonneuropathic diabetic subjects. The fol-
lowing exclusion criteria were applied to
subjects in all groups: smoking any
amount of cigarettes during the previous 6
months, subjects with diagnosed cardio-
vascular disease (coronary artery disease,
arrhythmia, congestive heart failure),
stroke or transient ischemic attack, periph-
eral vascular disease (symptoms of claudi-
cation and/or absence of peripheral
pulses), chronic renal disease, severe dys-
lipidemia (triglycerides 600 mg/dl or
cholesterol 300 mg/dl), or any other seri-
ous chronic disease requiring active treat-
ment. Subjects were also excluded if they
were on any of the following medications:
any type of antihypertensive drugs, lipid-
lowering agents, glucocorticoids, antineo-
plastic agents, psychoactive agents, or
bronchodilators. In addition, diabetic
patients with proliferative retinopathy,
peripheral somatic neuropathy, macroal-
buminuria (expressed as albumin-to-crea-
tinine ratio 300 g/mg), and/or on
insulin or troglitazone were excluded from
the study.
We also evaluated the skin microvascu-
lar reactivity at the foot level in 27 healthy
subjects and 101 diabetic patients who were
divided into four groups. The first group
consisted of 33 diabetic neuropathic
patients with a history of foot ulceration but
no peripheral vascular disease, the second
group of 23 diabetic patients with Charcot
arthropathy, the third group of 32 diabetic
patients with peripheral vascular disease
and neuropathy, and the fourth group of 13
diabetic patients without any complications.
All healthy subjects were free of any ill-
ness and did not take any medications. Spe-
cial emphasis was given to exclude anyone
with a history of hypertension, diabetes,
hypercholesterolemia, active tobacco use,
history of any systemic illness, or the use of
any antihypertensive, cardiac, or hormonal
medication. Patients with either type 1 or
type 2 diabetes were included. Patients with
nephropathy (creatinine 2 mg/l), severe
heart failure, or any other serious illness
were excluded from the study.
Further details of the characteristics of
the study population are shown in Tables 1
and 2. The study was approved by the
institutional review board, and consent was
obtained from all participants.
Methods
A history, physical examination, and fasting
plasma glucose measurement were per-
formed on all patients. Diabetic neuropathy
was diagnosed according to the San Anto-
nio Consensus Statement criteria (16). The
symptoms were evaluated by using a neu-
ropathy symptom score, and the clinical
signs were evaluated by using a neuropathy
disability score (17). Quantitative sensory
testing included the assessment of vibration
perception threshold using a Biothesiome-
ter and cutaneous perception threshold
using Semmes-Weinstein monofilaments
(18,19). The diagnosis of Charcot neu-
roarthropathy was made when gross
destruction of the joints of the mid-foot
that resulted in significant foot deformity
was present. Patients were characterized as
having peripheral vascular disease based on
the presence of one or more of the follow-
ing clinical features: claudication, absent
foot pulses, and/or abnormal invasive and
abnormal noninvasive vascular tests.
Each participant was studied after a 20-
min acclimatization period in a warm envi-
ronment (room temperature 2324C). We
used two single-point laser probes and a
DRT4 Laser Doppler Blood Flow Monitor
Table 1Characteristics of the forearm study subjects
Diabetic nonneuropathic patients Control subjects
n 42 69
Age (years) 54 9 49 9
Men/women 21/21 33/36
Type 2 diabetes 42
Diabetes duration (years) 4 5
BMI (kg/m
2
)* 32.3 6.3 27.3 4.3
HbA
1c
(%)* 8.0 1.6 5.6 0.4
Albumin-to-creatinine ratio 30 50
Neuropathy symptom score* 1.43 2.27 0.02 0.13
Neuropathy disability score* 0.8 1.45 0.15 0.62
Vibration perception threshold* 15.86 9.5 10.69 6.39
Data are means SD. *P 0.001.
Table 2Characteristics of the foot study subjects
Charcot Neuropathy and Diabetic patients Control
Neuropathy arthropathy peripheral vascular without subjects
(DN) (DA) disease (DI) complications (D) (C)
n 33 23 32 13 27
Age (years)* 56 9 57 9 60 8 39 10 52 13
Men/women 24/9 13/10 23/9 9/4 13/14
Type of diabetes (1/2) 12/21 5/18 16/16 8/5
Diabetes duration 21 12 17 11 25 13 17 7
BMI (kg/m
2
) 30.3 6.8 29.5 4.8 27.8 4.5 26.8 4.5 27.5 4.9
HbA
1c
(%) 8.7 2.7 8.7 2.0 8.9 0.9 9.9 4.3
Creatinine (mg/dl) 1.03 0.3 1.01 0.4 1.05 0.031 1.02 0.03
Neuropathy 3.2 2.9 2.9 2.5 3.5 2.8 0.5 1.1 0.1 0.4
symptom score
Neuropathy 19.3 6.1 21.8 3.9 18.7 6.7 0.5 1.2 0.4 1.2
disability score
Vibration perception 48 5 50 3.4 47 8 11 5 12 6
threshold
Semmes-Weinstein 6.6 0.7 6.9 0.4 6.6 0.5 4 0.5 4 0.5
monofilaments
Data are means SD. *DN, DA, and DI vs. D, P 0.001; DN, DA, and DI vs. D and C, P 0.001.
346 DIABETES CARE, VOLUME 24, NUMBER 2, FEBRUARY 2001
Nerve-axon reflex and skin vasodilation
(Moor Instruments, Millwey, Devon, U.K.)
to evaluate the skin microcirculation. Fore-
arm microcirculatory flow was measured
over the flexor surface of the forearm, and
foot microcirculatory flow was measured
over the dorsum of the foot. The blood flow
response was measured in response to ion-
tophoresis of each of three substances: 1%
acetylcholine chloride solution (a substance
that elicits both a neurovascular response
and endothelium-dependent vasodilation),
1% sodium nitroprusside (a substance that
does not elicit a neurovascular response,
but induces endothelium-independent
vasodilation), and deionized water (used as
a control during iontophoresis to measure
the vasodilation caused by the direct effect
of a constant current flow) (10). Deionized
water was iontophoresed in both anodal
mode (the same mode in which the ion-
tophoresis of acetylcholine is performed)
and cathodal mode (the mode that the ion-
tophoresis of sodium nitroprusside is per-
formed). The difference in these two modes
is the polarity of the iontophoresis chamber:
the chamber serves as the anode for ion-
tophoresis of acetylcholine, which has a
negative electrical charge, and as the cath-
ode for the iontophoresis of sodium nitro-
prusside, which has a positive electrical
charge. Therefore, the constant current has
an opposite direction when the polarity of
the chamber is changed.
The iontophoresis instrument (MIC1
iontophoresis system; Moor Instruments)
consists of an iontophoresis delivery vehicle
device that sticks firmly to the skin with the
help of adhesive tape. The device contains
two chambers that accommodate two sin-
gle-point laser probes. One probe is placed
within the chamber containing the ion-
tophoresis solution (thus measuring the
direct response to acetylcholine or sodium
nitroprusside iontophoresis), while the sec-
ond probe is placed outside but within
proximity (within 5 mm) to the ion-
tophoresis solution chamber, thus meas-
uring the indirect nerve-axonrelated
response that results from stimulation of the
C nociceptive nerve fibers. A small amount
(1 ml) of test solution was applied to the
iontophoresis chamber. Subsequently, a
constant current of 200 A for 60 s was
applied, achieving a dose of 6 mC/cm
2
between the iontophoresis chamber and a
second nonactive electrode placed 1015
cm proximal to the chamber. The two laser
probes recorded changes in skin blood flow.
Measurements were obtained for 40 s
before the iontophoresis, during the ion-
tophoresis, and 90 s after it (10,11). The
day-to-day reproducibility of the technique
was evaluated in five healthy subjects (four
men and one woman, ages 2339 years)
who were repeatedly tested at their foot
and forearm for 10 consecutive working
days. With use of a single-point laser probe,
the coefficient of variation (CV) for the base-
line blood flow before iontophoresis of
acetylcholine was 60.6% and for the maxi-
mal hyperemic response was 35.2% after
the iontophoresis of acetylcholine.
Statistical analysis
The results were recorded and tabulated
before revealing the patient category assig-
nations. Changes in microvascular blood
flow were expressed as the percentage of
increase over baseline, where median, first
quartile, and third quartile values are used
for comparisons. Parametric data were
expressed as means SD. Statistical analysis
was performed using the Minitab computer
software (State College, PA), using both
parametric and nonparametric tests. All tests
were two-tailed, with significance taken as
P 0.05. For between-group comparisons,
we used pairedt test for parametric data and
Kruskal-Wallis test for nonparametric data.
RESULTS
Forearm level
The results of the iontophoresis are shown
in Table 3. To evaluate the degree of vasodi-
lation that is specific to the neurovascular
response, we measured the capillary blood
flow in a skin area in direct contact with
acetylcholine and in an adjacent skin area
not in direct contact with it. The latter rep-
resents the nerve-axonrelated portion of
the total response. The percentage contri-
bution of the nerve-axonrelated response
to the total response was similar between
nonneuropathic diabetic patients and the
control group after the iontophoresis of
acetylcholine (35 and 31%, respectively,
NS). In both the nonneuropathic diabetic
patients and control group, the percentage
contribution of the nerve-axonrelated
response to the total response was signifi-
cantly less after the iontophoresis of either
sodium nitroprusside (13 and 10%, respec-
tively, P 0.01) or deionized water (16
and 17%, respectively, P 0.01). No sig-
nificant difference was seen between the
percentage contribution of the nerve-
axonrelated reflex to the total response to
sodium nitroprusside and to deionized
water both in anodal and cathodal mode in
Table 3The contribution of nerve-axon reflex-related vasodilation to the total response to acetylcholine, sodium nitroprusside, and deionized water
at the forearm level
Nonneuropathic diabetic patients Control subjects
Total response to Ach 835 (2891476) 1,181 (5472,299)
Nerve-axonrelated response to Ach 365 (120513) 338 (207706)
The % contribution of nerve-axon response to the total response to Ach 35 (1683)* 31 (1760)*
Total response to SNP 525 (307974) 880 (4452,178)
Nerve-axonrelated response to SNP 77 (22230) 118 (40769)
The contribution of nerve-axon response to the total response to SNP 13 (634) 10 (322)
Total response to W, anodal mode 83 (15400) 300 (65897)
Nerve-axonrelated response to W 14 (160) 35 (8141)
The % contribution of nerve-axon response to the total response to W 16 (254) 17 (440)
Total response to W, cathodal mode 111 (45315) 108 (20252)
Nerve-axonrelated response to W 11 (160) 35 (022)
The % contribution of nerve-axon response to the total response to W 5 (135) 6 (027)
Data are medians (25th75th quartiles). Ach, acetylcholine; SNP, sodium nitroprusside; W, deionized water. *Ach vs. SNP and W, P 0.01.
DIABETES CARE, VOLUME 24, NUMBER 2, FEBRUARY 2001 347
Hamdy and Associates
both the nonneuropathic diabetic patients
and control group (NS). This is consistent
with the fact that acetylcholine specifically
stimulates C nociceptive fibers and the
nerve-axonrelated reflex, whereas sodium
nitroprusside and deionized water do not.
The contribution of the neurovascular
response to the total response to acetyl-
choline is approximately one-third of the
total response and is not compromised by
diabetes at the forearm level.
Foot level
The results of the iontophoresis are shown in
Table 4. In response to iontophoresis of
acetylcholine, the percentage contribution of
the nerve-axonrelated response was similar
to that seen at the forearm level in both the
diabetic patients without complications and
the healthy control subjects (29 and 36%,
respectively, NS). The diabetic neuropathic
patients had a significantly lower median
increase of capillary blood flow over baseline
in response to acetylcholine compared with
the diabetic patients without complications
and the control group (P 0.01) (Fig. 1).
The neurovascular response was markedly
decreased in all three neuropathic groups
when compared with diabetic patients with-
out complications and the control group.
The contribution of the nerve-axonrelated
response to the total response was 8% in
diabetic patients with neuropathy (P
0.01), 5% in diabetic patients with Charcot
arthropathy (P 0.01), and 20% in diabetic
patients with neuropathy and peripheral
vascular disease (P 0.01). The nerve-
axonrelated response to sodium nitro-
prusside and to the anodal and cathodal
iontophoresis of deionized water was simi-
lar to the response observed in the upper
extremity.
CONCLUSIONS In the present
study, we have shown that in healthy sub-
jects and in nonneuropathic diabetic
Table 4Contribution of nerve-axon reflex-related vasodilation to the total response to acetylcholine, sodium nitroprusside, and deionized water
at the foot level
Charcot Neuropathy and Diabetic patients Control
Neuropathy arthropathy peripheral vascular without subjects
(DN) (DA) disease (DI) complications (D) (C)
Total response to Ach 90 (15378) 227 (86554) 74 (1212) 578 (1521,858) 411 (148541)
Nerve-axonrelated response to Ach 4 (026) 13 (152) 5 (052) 118 (19304) 153 (60264)
The % contribution of nerve-axon response to the total 8 (031)* 5 (027) 20 (070) 29 (752) 36 (1888)
response to Ach
Total response to SNP 89 (31227) 80 (74400) 86 (7239) 234 (141520) 234 (129590)
Nerve-axonrelated response to SNP 10 (024) 2 (032) 1 (012) 27 (887) 48 (16108)
The % contribution of nerve-axon response to the total 8 (031) 10 (029) 2 (018) 12 (235) 9 (476)
response to SNP
Total response to W, Anodal mode 8 (040) 12 (150) 19 (031) 238 (35427) 33 (11107)
Nerve-axonrelated response to W 0 (013) 6 (012) 3 (010) 23 (728) 12 (025)
The % contribution of nerve-axon response to the total 11 (0100) 43 (6106) 26 (081) 13 (248) 18 (6111)
response to W
Total response to W, Cathodal mode 4 (014) 12 (038) 18 (042) 28 (10109) 25 (843)
Nerve-axonrelated response to W 0 (09) 1 (012) 0 (015) 11 (142) 3 (011)
The % contribution of nerve-axon response to the total 35 (0100) 18 (6106) 4 (081) 41 (248) 0 (6111)
response to W
Data are medians (25th75th quartiles). Ach, acetylcholine; SNP, sodium nitroprusside; W, deionized water. *DN vs. D and C, P 0.01; DA vs. D and C, P 0.01;
DI vs. D and C, P 0.01; Ach vs. SNP and W, P 0.01.
Figure 1Total and neurovascular (N) change in skin blood flow in response to acetylcholine at the
foot level. The median, first quartile, and third quartile and the range are shown. The total response is
significantly lower in neuropathic diabetic patients than it is in control subjects and diabetic patients
without neuropathy (P 0.01). The percentage contribution of neurovascular response to the total
response is also significantly lower in neuropathic diabetic patients than in control subjects and diabetic
patients without neuropathy (P 0.01).
348 DIABETES CARE, VOLUME 24, NUMBER 2, FEBRUARY 2001
Nerve-axon reflex and skin vasodilation
patients, at both the forearm and foot lev-
els, the microvascular vasodilation that is
related to the neurovascular response
accounts for approximately one-third of
the total vasodilation that is observed after
the iontophoresis of acetylcholine. This
portion is markedly decreased in the pres-
ence of diabetic neuropathy.
The total microvascular vasodilation in
response to acetylcholine is currently con-
sidered to represent the sum of direct stim-
ulation of the endothelium by acetylcholine
and of the vasodilation that is related to the
nerve-axon reflex (20). However, the mag-
nitude of the contribution of each of these
two factors to the total vasodilation has not
been adequately studied, and the currently
available data are conflicting. Thus, although
some studies have suggested a considerably
higher contribution of the neurovascular
response, the techniques used did not allow
the precise quantification of this contribu-
tion (8,21). On the other hand, another
study has shown that local sensory inhibi-
tion by topical application of lignocaine and
prilocaine did not have an effect on the total
vasodilatory response to the iontophoresis of
acetylcholine (22). The main problem in
interpreting these data, though, lies in the
fact that there is no evidence that topical
application of lignocaine abolishes the
nerve-axon reflex, since it may cause local
anesthesia via mechanisms that are not
affecting the antidromic stimulation of local
C nociceptive fibers. This is further empha-
sized by the findings of a previous study
that showed that deep subcutaneous injec-
tion of lignocaine does inhibit the nerve-
axonrelated vasodilation in response to the
iontophoresis of acetylcholine (23).
In the present study, we have used a
chamber that can accommodate two single-
point laser probes that can measure the total
and the nerve-axon reflex-related vasodila-
tion. This technique can satisfactorily mea-
sure the two responses separately, making it
possible to evaluate the relative contribution
of the neurovascular response to the total
response with an adequate reliability. Fur-
thermore, we have studied subjects with
and without peripheral neuropathy rather
than testing with local anesthesia, which, as
mentioned previously, has questionable
effects on the nerve-axon reflex. Finally, it
should be remembered that under condi-
tions of stress (such as injury or inflamma-
tion), hyperemia is necessary not only in the
injured area alone but in a considerably
larger area that surrounds the injured site.
Because this response depends mainly on a
normal nerve-axon reflex, our findings make
the point that this response, under normal
conditions, is one-third of the maximal
achievable vasodilation and that this is
drastically reduced in the presence of dia-
betic neuropathy.
Single-point laser probe measurements
are known to have a considerably high CV,
whereas the use of laser scanners reduces
this variability (10,16). However, with laser
scanners, one cannot evaluate the nerve-
axon response, a measurement that can be
done only with use of the single-point laser
technique. The large number of subjects in
each studied group compensates for the
high variability and does not affect the valid-
ity of the conclusions regarding the contri-
bution of nerve-axon response to total
vasodilation. On the other hand, the high
variability does not allow the direct com-
parison of the vasodilatory response among
the various studied groups, which makes
this study prone to type 2 statistical error.
Therefore, it is recommended that for reli-
able data regarding these questions, the
reader is directed to studies that have specif-
ically addressed this question and used the
appropriate techniques, including the use of
a Laser Scanner Imager (10,11,2426).
In contrast to acetylcholine, sodium
nitroprusside causes vasodilation by
directly stimulating the vascular smooth
muscle cell and does not specifically stim-
ulate the C nociceptive fibers. This result
can be seen in the present study by the
small nerve-axonrelated vasodilation
achieved with sodium nitroprusside, simi-
lar to that achieved by deionized water,
which can be attributed to a nonspecific
galvanic effect of the constant current that
is used for the iontophoresis (27). There-
fore, we believe that the presented data
also provide further evidence of different
pathways through which acetylcholine and
sodium nitroprusside cause vasodilation in
the skin microcirculation.
The iontophoresis of deionized water in
the same polarity with that of acetylcholine
(i.e., with an anodal constant current) has
been previously shown to lead to a small
nonspecific galvanic effect (20,21). In con-
trast, iontophoresis with a cathodal current,
as used for the iontophoresis of sodium
nitroprusside, has been reported in one
study to result in a significant nonspecific
vasodilatory response (22). In the present
study, we have not found such an exagger-
ated response, and both anodal and cathodal
modes elicited very similar responses. The
main differences between previous studies
and the present study that may explain this
discrepancy are the duration and amplitude
of the current used for iontophoresis. Thus,
in our unit, we apply 200 A for 60 s. This
produces maximal specific vasodilation with
a minimal nonspecific vasodilation. This is
in sharp contrast with a previous study in
which three rather small pulses of ion-
tophoresis were performed over a period of
10 min, raising the question as to whether
maximal vasodilation was achieved.
In a previous study, we showed that
diabetes impairs the total endothelium-
dependent and endothelium-independent
vasodilation at the forearm level, a skin
area that is rarely affected by diabetic neu-
ropathy (11). In addition, the present
study shows that this reduction is inde-
pendent of the nerve-axonrelated
response. A direct effect of diabetes on
endothelium function or smooth muscle
cells should therefore be considered as the
main cause of the observed impaired
vasodilation in response to acetylcholine
and sodium nitroprusside. We have previ-
ously shown that differences exist between
the forearm and foot microcirculation
beds, with the foot vasodilatory response
being approximately half that of the
response at the forearm level (11). Similar
results were observed in the present study.
Neuropathy has been shown to reduce
the vasodilatory response at the foot level,
irrespectively of the presence or absence of
peripheral vascular disease (10,11). In the
present study, the nerve-axonrelated
response in diabetic patients during specific
stimulation of the C fibers with acetylcholine
was markedly decreased, being similar to
that observed with sodium nitroprusside.
Thus, this is another indication that neu-
ropathy renders the diabetic foot function-
ally ischemic, as blood flow fails to increase
under conditions of stress.
In summary, we have shown in the
present study that the neurovascular vasodi-
lation response accounts for approximately
one-third of the total acetylcholine-induced
vasodilation response at both the forearm
and foot levels of healthy subjects and non-
neuropathic diabetic patients. The presence
of diabetic neuropathy at the lower extrem-
ity results in a significant reduction in the
total vasodilatory response to acetylcholine
and to an even more pronounced reduction
in the percentage contribution of the neu-
rovascular response to the total skin
vasodilatory response to acetylcholine.
Acetylcholine and sodium nitroprusside
cause vasodilation in the skin microcircula-
DIABETES CARE, VOLUME 24, NUMBER 2, FEBRUARY 2001 349
Hamdy and Associates
tion through different pathways. Finally, the
technique used in this study may be partic-
ularly helpful in developing new methods
that can objectively evaluate the efficacy of
new treatments on small-fiber function.
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