PERSPECTIVE

Neurophysiological, Neuroimmunological, and

Neuroendocrine Basis of Pruritus
Martin Steinhoff1, John Bienenstock2, Martin Schmelz3, Marcus Maurer4, Ed Wei5 and Tamás Bı́ró6

Pruritus (itch) can be defined as an unpleasant cutaneous sensation associated with the immediate desire to
scratch. Recent findings have identified potential classes of endogenous ‘‘itch mediators’’ and establish a
modern concept for the pathophysiology of pruritus. First, there in no universal peripheral itch mediator, but
disease-specific sets of involved mediators. Second, numerous mediators of skin cells can activate and sensitize
pruritic nerve endings, and even modulate their growth. Our knowledge of itch processing in the spinal cord
and the involved centers in the central nervous system is rapidly growing. This review summarizes the current
information about the significance of neuron–skin interactions, ion channels, neuropeptides, proteases,
cannabinoids, opioids, kinins, cytokines, biogenic amines, neurotransmitters, and their receptors in the
pathobiology of pruritus. A deeper understanding of these circuits is required for the development of novel
antipruritic strategies.
Journal of Investigative Dermatology (2006) 126, 1705–1718. doi:10.1038/sj.jid.5700231

Introduction
Pruritus (itch) can be defined as an
unpleasant cutaneous sensation asso-
ciated with the immediate desire to
scratch. Teleologically, pruritus may
be interpreted as part of the body’s
defense mechanism by which we
dispose of potential dangerous organ-
isms or stimuli. Chronic or intense
scratching leads to the development
of skin lesions and the release of
inflammatory mediators that potentially
induce or aggravate pruritus resulting
in reinforcement of scratching. This
‘‘itch–scratch’’ cycle, unfortunately, is
frequently resistant to topical and
systemic therapy (Figure 1, Table S1).
Pruritus is one of the most common
symptoms in dermatology and general
medicine. It can be initiated during
inflammation, cancer, metabolic dis-
eases, infection, psychiatric diseases,
drug application, stress, and others.
Current evidence clearly indicates the
existence of an interactive network
between the skin and the peripheral
as well as the central nervous system to
regulate and respond to pruritic stimuli
(Figure 1). It became evident that
specified sensory nerves and their
receptors are crucially involved in the
pathophysiology of pruritus. Thus, prur-
itus is not merely a submodality of
pain, but an individual sensation of our
sensory nerve system.
Recent observations clearly expand
our knowledge of potential classes of
endogenous ‘‘itch mediators’’ (re-
viewed in Stander and Steinhoff,
2002; Yosipovitch et al., 2003) and
established a modern concept of the
pathophysiology of pruritus (Table 1).
In other words, different peripheral itch
mediators and receptors may be in-
volved with a different impact among
various pruritic diseases (e.g. atopic
dermatitis, urticaria, renal, and chole-
static pruritus). However, the impor-
tance of the central nervous ‘‘itch
centers’’ under physiological and
pathophysiological conditions is still at
the beginning of being understood. This
review summarizes the current knowl-
edge about the significance of various
mediators and receptors in the patho-
physiology of pruritus. Owing to limited
space, several important papers could
not be cited. A prolonged reference
version can be found in the supplement.
Neurophysiology of itch
Primary afferent pruriceptive neurons.
According to the intensity hypothesis
of itch, low-level activation of un-
specific nociceptors would induce
pruritus, whereas higher discharge fre-

1
Department of Dermatology, IZKF Münster, Ludwig Boltzmann-Institute for Immunobiology of the Skin, University Hospital Muenster, Muenster, Germany;
2
Department of Pathology and Molecular Medicine, The Brain-Body Institute, McMaster University, St Joseph’s Healthcare Hamilton, Ontario, Canada;
3
Department of Anesthesiology and Critical Care Medicine, Faculty of Clinical Medicine Mannheim, University of Heidelberg, Mannheim, Germany;
4
Department of Dermatology and Allergy, Charité University of Berlin, Berlin, Germany; 5School of Public Health, University of California, Berkeley, California,
USA and 6Department of Physiology, Medical and Health Science Center, Research Center for Molecular Medicine, University of Debrecen,
Debrecen, Hungary
Correspondence: Dr Martin Steinhoff, Department of Dermatology, IZKF Münster, Ludwig Boltzmann-Institute for Immunobiology of the Skin, University
Hospital Münster, Von-Esmarch-Straße 58, Münster D-48149, Germany. E-mail: msteinho@uni-muenster.de
Abbreviations: AD, Alzheimer disease; BDNF, brain-derived neurotrophic factor; CB, cannabinoid; CGRP, calcitonin gene-related peptide;
CRH, corticotropin-releasing hormone; ET-1, endothelin-1; MC, mast cell; NGF, nerve growth factor; PAR, proteinase-activated receptor; SP, substance P;
TNF-a, tumor necrosis factor alpha; TRP, transient receptor potential; VIP, vasoactive intestinal polypeptide
Received 19 July 2005; revised 30 December 2005; accepted 6 January 2006

& 2006 The Society for Investigative Dermatology www.jidonline.org 1705

 M Steinhoff et al.
Basis of Pruritus

Langerhans cell histamine. They comprise about 20%

of the mechano-heat-insensitive class
of C-fibers.
Brain The pruritogenic potency of inflam-
Epidermis matory mediators is characterized by
Immune cells their ability to activate histamine-posi-
tive mechano-insensitive C-nocicep-
tors. However, concomitant activation
of mechano-sensitive and mechano-
insensitive histamine-negative nocicep-
tors will decrease the itch. Therefore,
Blood vessel
itch sensation is apparently based on
Protons, kinins,
proteases, amines, both, activity in the pruriceptors and
prostanoids, cytokines
Neuropetides absence of activity in the pain-mediat-
ing nociceptors.
DRG
Additional primary afferents involved
in producing itch. Histamine-sensitive
C-fibers have been found among the
mechano-insensitive afferent C-fibers.
Spinal cord
They are characterized by very high
Figure 1. Pathophysiology of pruritus. Exogenous as well as endogenous factors released by immune transcutaneous electrical thresholds and
cells, epithelial cells, or endothelial cells induce activation of signal cascades from the periphery via are involved in the generation of the
dorsal root ganglia (DRG) and spinal cord to the central nervous system (CNS). Activation of specific
axon reflex erythema (Schmelz et al.,
areas in the CNS results in perception of itch leading to a scratch response. By a direct axon reflex
mechanism, sensory nerve endings release neuropeptides (Table 1), which may aggravate the itch 2000a). Recently, focal electrical stimu-
response by stimulating release of pruritic mediators from MCs, endothelial cells, and epithelial cells. lation with low intensity but high fre-
Whether neuropeptides may also trigger the release of antipruritic agents from these cells is only poorly quency has been shown in humans to
understood. induce itch (Ikoma et al., 2005). Inter-
estingly, the electrically induced itch
was not accompanied by an axon reflex
quencies would provoke pain. How- by a particular low conduction velo- erythema, suggesting that the activated
ever, application of low concentrations city, large innervation territories, me- fibers do not belong to the histamine-
of algogens generally does not cause chanical unresponsiveness, and high sensitive pruriceptors described above.
itch, just less intense pain. Further, transcutaneous electrical thresholds
intraneural electrical microstimulation (Schmelz et al., 2003). In line with the Specific spinal pruriceptive neurons.
of human afferent nerves induces either large innervation territories of these Using the cat spinal cord, a specific
pain or, less commonly, pruritus. In- fibers, two-point discrimination for class of dorsal horn neurons projecting
creasing the stimulation frequency in- histamine-induced itch is poor (15 cm to the thalamus has been demonstrated,
creases the intensity of pain or itch, but in the upper arm). which respond strongly to histamine
no switch from pruritus to pain is The relative prevalence of the dif- administered to the skin by iontophor-
observed. Therefore, a dedicated neuro- ferent C-fiber types has been estimated esis (Andrew and Craig, 2001). The
nal system for encoding itch could be from recordings in the superficial per- time course of these responses was
predicted. C-fibers, responding to hista- oneal nerve (Schmidt et al., 1997). similar to that of itch in humans and
mine application in parallel to the itch About 80% are polymodal nociceptors, matched the responses of the periph-
ratings of subjects, have been discovered which respond to mechanical, heat, eral C-itch fibers. These units were also
among the group on mechano-insensi- and chemical stimuli. The remaining unresponsive to mechanical stimula-
tive C-afferents confirming that there is a 20% do not respond to mechanical tion and differed from the histamine-
specific pathway for itch (Figure 1, stimulation. These fibers are mainly insensitive nociceptive units in lamina I
Tables 1, 2, and S1). In contrast, the ‘‘mechano-insensitive nociceptors’’, of the spinal cord. In addition, their
most common type of C-fibers, ‘‘poly- which are activated by chemical sti- axons had a lower conduction velocity
modal’’ nociceptors are either insensi- muli, and can be sensitized to mechan- and anatomically distinct projections to
tive to histamine or only weakly ical stimulation in the presence of the thalamus. Thus, the combination of
activated by it (Schmelz et al., 2003). inflammation (Schmelz et al., 2000b). dedicated peripheral and central neu-
Thus, this fiber subtype cannot account This latter characteristic led to the rons with a unique response pattern to
for the prolonged itch induced by the name ‘‘sleeping nociceptor’’. Among pruritogenic mediators and anatomi-
intradermal application of histamine. the mechano-insensitive afferent C- cally distinct projections to the thala-
The histamine-sensitive or ‘‘itch’’ fibers, there is a subset of units, which mus provides the basis for a specific
fibers or pruriceptors are characterized have a strong and sustained response to neuronal pathway for itch.

1706 Journal of Investigative Dermatology (2006), Volume 126

 M Steinhoff et al.
Basis of Pruritus

Table 1. Involvement of neuromediators in pruritus, pain, and burning (selected)

Neuromediator Receptor Source Target cells/function References

Acetylcholine Nicotinergic and muscarinergic Autonomic cholinergic Mediates itch in atopic Grando (1997); Schmelz et al.
Acetylcholine receptors nerves, keratinocytes, dermatitis patients; M3R (2000a, b)
lymphocytes, melanocytes probably involved in itch

Catecholamines, Adrenergic receptors Autonomic adrenergic Pain transmission Haüstein (1990); Hundley
noradrenaline nerves, keratinocytes, and Yosipovitch (2004)
melanocytes

Substance P Tachykinin (neurokinin) Sensory nerve fibers Low (physiologically relevant) Janiszewski et al. (1994);
receptor concentrations: priming of MCs; Okabe et al. (2000); Scholzen
release of TNF-a, histamine, and Luger (2004)
leukotriene B4, prostaglandin
D2 from MCs (agents involved
in pruritus and burning)

Neurokinin A Tachykinin (neurokinin) Sensory nerve fibers Up-regulation of keratinocyte Burbach et al. (2001)
receptor nerve growth factor expression

VIP Vasoactive intestinal peptide/
pituitary adenylate cyclase
activating peptide (VPAC)
receptors
Sensory nerve fibers,
Merkel cells
Histamine release from MCs; Steinhoff et al. (2003b and
allodynia (no allodynia in AD!) references therein)
intensifies acetylcholine
induced itch in atopic dermatitis
patients (together with
acetylcholine)

Pituitary adenylate VPAC receptors Autonomic and sensory Involved in flush, vasodilatation, Delgado et al. (2001 and
cyclase-activating nerve fibers, lymphocytes, pain, neurodegeneration; references therein)
polypeptide dermal endothelial cells pruritus? Induces release of
histamine from MCs

CGRP CGRP receptors Sensory nerve fibers Pain transmission, prolongation Steinhoff et al. (2003b and
of itch latency following SP references therein); Brain and
injection (inhibitory effect on Grant (2004); Brain and
itching); sensitization of Williams (1988)
receptive endings; increase of
CGRP fibers in itchy skin
diseases

MSH Melanocortin receptors Melanocytes, keratinocytes,
endothelial cells,
Langerhans cells, MCs,
fibroblasts, monocytes
CRH CRH-R1, -2 CRH-R1: keratinocytes,
MCs
CRH-R2: bone-marrow
MCs
Releases histamine from MCs;
pruritus
Release of histamine, cytokines,
TNF-a, vascular endothelial
growth factor from MCs
CRH-like-immunoreactivity on
sensory nerves (rat)
Steinhoff et al. (2003b and
references therein)
Skofitsch et al. (1995);
Slominski et al. (1995);
Theoharides et al. (1998);
Slominski and Wortsman
(2000); Venihaki et al. (2001);
Lytinas et al. (2003);
Kempuraj et al. (2004); Cao
et al. (2005)

Opioids m-, k-, d-opioid receptors (partly Nerves, keratinocytes Antipruritic effect of m-opioid
receptor-independent cell antagonists (central effect) and
activation) k-opioid agonists (spinal cord
level); opioid agonists do not
provoke itch upon injection or
intradermal application;
Onigbogi et al. (2000);
Andrew and Craig (2001);
Stander et al. (2003); Blunk
et al. (2004); Bigliardi-Qi
et al. (2005)

Table 1 continued on following page

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 M Steinhoff et al.
Basis of Pruritus

Table 1. continued
Neuromediator Receptor Source Target cells/function References

m-opioid receptor upregulation

in atopic dermatitis
Endocannabinoids CB receptors Nerves, keratinocytes Antipruritic in the periphery Maccarrone et al. (2003);
Ibrahim et al. (2005); Stander
et al. (2005)

Endothelins Endothelin receptors A, B Endothelium, MCs Burning itch, degraded by Katugampola et al. (2000);
chymase via ETA receptor Maurer et al. (2004)
activation

Kinins Bradykinin receptors Endothelial cells, Bradykinin induces pain over Hayashi and Majima (1999)
immunocytes pruritus; bradykinin B2 receptor
antagonists reduce itch

Kallikreins, proteases Partly by proteinase-activated
receptors (PARs, tryptic
enzymes)
Keratinocytes, endothelial Massive itch behavior in mice
cells, MCs, platelets overexpressing epidermal
kallikrein 7; potential role of
other kallikreins; chymase
degrades pruritic and antipruritic
peptides; tryptase induces
inflammation and itch by a
neurogenic mechanism via PAR2
Steinhoff et al. (2000);
Steinhoff et al. (2003a, b);
Lundequist et al. (2004); Ny
and Egelrud (2004); Steinhoff
et al. (2005)

Neurotrophins (NGF, Specific receptors trk A: NGF; NGF: keratinocytes, MCs, NGF levels enhanced in atopic Kanda and Watanabe (2003);
NT-4, BDNF) trk B: NT-4, BDNF; trk C: NT-3 fibroblasts, eosinophils. dermatitis and epidermal barrier Kimata (2003); Groneberg
BDNF: eosinophils disruption; induces tryptase et al. (2005); Raap et al.
release from MCs; inducible by (2005)
histamine; trk A: enhanced in
keratinocytes during
inflammation; NT-4: enhanced
in AD; induces sprouting.
BDNF: increases eosinophil
chemotaxis levels in AD, and
inhibits apoptosis. Sensitization
of receptive nerve endings,
upregulation of neuronal
neuropeptides, and TPV1
1
VPAC, Vasoactive intestinal peptide/pituitary adenylate cyclase activating peptide.

Central itch processing. The itch-selec-
tive units in lamina I of the spinal cord
form a distinct pathway projecting to
the posterior part of the ventromedial
thalamic nucleus, which projects to the
dorsal insular cortex, a region that has
been shown to be involved in a variety
of interoceptive modalities like thermo-
ception, visceral sensations, thirst, and
hunger. The supraspinal processing
of itch and its corresponding scratch
response have recently been investi-
gated in man by functional positron
emission tomography (Darsow et al.,
2000). Induction of itch by intradermal
histamine injections and histamine
skin-prick-induced co-activation of the
anterior cingulate cortex, supplemen-
tary motor area, and inferior parietal
lobe predominantly in the left hemi-
sphere (Mochizuki et al., 2003 and
references therein). The significant co-
activation of motor areas supports the
familiar observation that itch is inher-
ently linked to a desire to scratch.
The multiple activated sites in the brain
after itch induction argue against the
existence of a single itch center and
reflect the multidimensionality of itch.
Thus, a broad overlap of activated
brain areas is evident for pain and itch
(Drzezga et al., 2001 and references
therein). However, subtle differences in
the activation pattern between itch and
pain have been described. In contrast
to pain, itch seems to be characterized
by a lack of secondary somatosensory
cortex activation on the parietal oper-
culum and by left hemispheric dom-
inance (Drzezga et al., 2001). In
addition, the periaqueductal gray mat-
ter was activated only when painful
and itching stimuli were simulta-
neously applied. This activation was
combined with reduced activity in the
anterior cingulate, dorsolateral prefron-
tal cortex, and parietal cortex, suggest-
ing that the periaqueductal gray matter
might be involved in the central inhibi-
tion of itch by pain (Mochizuki et al.,
2003).

1708 Journal of Investigative Dermatology (2006), Volume 126


Table 2. TRP channels with potential role in the pathogenesis and therapy of itch and pain
Receptor Expression in the skin
TRPV1 Sensory neurons
MCs
Epidermal keratinocytes
Hair follicle keratinocytes
Langerhans cells
Smooth muscle
Sebocytes
TRPV2 Sensory neurons
MCs
TRPV3 Sensory neurons
(interacting with TRPV1)
Epidermal keratinocytes
TRPV4 Sensory neurons
Epidermal keratinocytes
MCs
TRPM8 Sensory neurons
TRPA1 Sensory neurons
Skin–nerve interactions and itch
The skin is highly innervated by pri-
mary sensory nerves, postganglionic
cholinergic parasympathetic, and post-
ganglionic sympathetic nerves, result-
ing in a complex afferent/efferent
M Steinhoff et al.
Basis of Pruritus
Activator/sensitizer Target cells/functions References
Exogenous vanilloids (capsaicin, Responds to noxious heat, capsaicin, Biro et al. (1997); Caterina et al.
resiniferatoxin) endovanilloids, anandamide, (1997); Caterina and Julius
prostaglandins, desensitization (2001); Stander et al. (2003);
T4431C Depletes neuropeptides from sensory Yosipovitch et al. (2003); Lazar
neurons et al. (2004); Biro et al. (2005);
Bodo et al. (2005); Xu et al.
Acidosis Long-term antipruritic effect: suspends (2005)
interplay between sensory neurons and
MCs
Endovanilloids Modulates dendritic cell function
Activated by histamine, Affects epidermal and hair follicle
bradykinin, eicosanoids, ATP, proliferation, differentiation, apoptosis
prostaglandins, neurotrophins, etc and cytokine release
Camphor desensitizes TRPV1 via Increased expression in epidermal
protein kinase C keratinocytes of prurigo nodularis
patients
High Ca2+ permeability
Conductance B100 pS
T4531C TRPV3 modulates TRPV1-mediated pain Stokes et al. (2004)
and itch
T4311C TRPV3 knockouts deficit in response to Peier et al. (2002b); Moqrich
innocuous (mostly TRPV3 range) and et al. (2005)
noxious heat (rather TRPV1 range)
TRPV3 and TRPV4 may modulate
epidermal osmotic pressure
T4251C TRPV4 is activated by eicosanoids Watanabe et al. (2003); Stokes
Eicosanoids TRPV2 and TRPV4 stimulated by MCs in et al. (2004)
a protein kinase A-dependent manner
T: 8–281C Antipruritic, anti-irritative (induce Wei and Seid (1983); Peier et al.
sensation of cooling) (2002a)
Menthol, icilin, and their analogs
T: below 171C Noxious cold sensation Clapham (2003); Story et al.
Activated by mustard and Mechano-transduction of hair cells (2003), Bandell et al. (2004);
cinnamon oils, raw garlic, Tominaga and Caterina (2004);
sensitized by camphor, McKemy (2005); McPherson
cannabinoids, bradykinin et al. (2005); Reid (2005)
(coupled to bradykinin-2R)
Signaling via phospholipase C, —
protein kinase C
neuronal network in the skin. It choline), certain neuropeptides (e.g.
is further discussed that in the facial substance P (SP), calcitonin gene-
skin some parasympathetic nerves exist related peptide (CGRP), opioids,
associated with flushing. These neurons cannabinoids (CB)), and certain neuro-
utilize, among others, classical neuro- trophins (nerve growth factor (NGF),
transmitters (catecholamines, acetyl- neurotrophin-4).
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 M Steinhoff et al.
Basis of Pruritus

Certain subtypes of unmyelinated C-
fibers also project into the epidermis
(Kennedy et al., 1994). Thus, neurome-
diators may directly communicate with
keratinocytes or Langerhans cells, and
vice versa. For example, CBs stimulate
the release of b-endorphin from kerati-
nocytes, thereby activating sensory
neurons resulting in the modulation of
pain (Ibrahim et al., 2005). From that it
is evident that dysregulation of skin
function (pH changes, trauma, dis-
rupted barrier function, inflammation,
infection, UV light) can directly or
indirectly stimulate sensory nerve
endings, thereby inducing pruritus
(Figure 2). Therefore, cell–nerve inter-
actions in the epidermis as well as the
dermis influence skin-derived pruritus
(Figure S1, Tables 1 and 2).
Role of the epidermis in itch sensation.
Itch sensations can be induced owing
to damage to the skin barrier function
in the dry skin (xerosis) and atopic
eczema as well as papulosquamous
diseases such as psoriasis and lichen
planus. In this context, itching most
probably is not related to mast cells
(MCs). The epidermis itself is inner-
vated by sensory nerve endings anato-
mically associated with keratinocytes
and Langerhans cells. Recent studies
have demonstrated that – upon stimula-
tion – keratinocytes are capable of
releasing pruritic as well as antipruritic
mediators such as endovanilloids,
endorphins, neuropeptides, proteases,
and cytokines (Figure 2, Table 1). With
respect to the role of dry skin in
pruritus, Nojima et al. (2004) have
shown in a murine model that dry skin
induces enhanced c-fos expression,
which reflects activation of spinal cord
neurons. SP as well as CRF decrease
the electric potential in keratinocytes as
well as did skin barrier disruption.
Thus, ion channels including the
voltage-gated, ATP-gated (Inoue et al.,
2005), and transient receptor potential
(TRP)V-gated may be directly involved
in the transmission of pruritus via
keratinocyte activation in the dry
skin. Keratinocytes express a variety

Inflammation

Vasodilatation

Plasma extravasation

Recruitment leukocytes

Itch CGRP R
(NKIR) etc.
4
Brain 3

SP
CGRP
2 Endogenous/
exogenous
proteinases

Dorsal root PAR2

ganglia

5
8 PAR2
9 Inflammatory
Central Peripheral cells
ending ending

Primary afferent
sensory neuron 1

Tryptase
Spinal cord − 6

CGRP
7
− +
Degradation Vasodilatation

Figure 2. PAR2 mediates protease-induced inflammation and pruritus by a neurogenic mechanism (modified from Steinhoff et al. (2000, 2003b)). (1) Tryptase
released from degranulated MCs activates PAR2 at the plasma membrane of sensory nerve endings. (2) Activation of PAR2 by tryptase, trypsins, various
kallikreins, probably exogenous proteases (bacteria, house-dust mite) stimulates the release of CGRP and the tachykinins SP and neurokinin A (NKA) from
sensory nerve endings. (3) CGRP interacts with the CGRP1 receptor to induce arteriolar dilation and hyperemia. (4) SP interacts with the neurokinin-1 receptor
on endothelial cells of post-capillary venules to cause gap formation and plasma extravasation. Hyperemia and plasma extravasation cause edema during
inflammation. (5) SP may stimulate degranulation of MCs, providing a positive feedback mechanism. (6) Tryptase degrades CGRP and terminates its effects. (7)
CGRP inhibits SP degradation by neutral endopeptidase and also enhances SP release, thereby amplifying the effects. (8) Mediators from MCs and other
inflammatory cells stimulate the release of vasoactive peptides from sensory nerves and also sensitize nerves. (9) At the spinal cord level, PAR2-induced
intracellular Ca mobilization leads to the release of CGRP (and SP) from central nerve endings, thereby activating neurokinin-1 receptor and CGRPRs to transit
itch responses to the central nervous system.

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of receptors (neuropeptide receptors,
neurotrophin receptors (for NGF, neuro-
trophin-4), CB receptors, proteinase-
activated receptor-2 (PAR2), and the
TRPV1 ion channel, all of which have
been demonstrated to be involved in
transmitting itch sensations. Interest-
ingly, different trigger factors are
capable of stimulating the release of
pruritogenic or antipruritogenic factors
from keratinocytes. For example, pros-
taglandin E2 induces the release of
neurotrophin-4 from keratinocytes
(Kanda et al., 2005). Both, the hista-
mine H1 and H2 receptors are ex-
pressed by keratinocytes and may be
involved in epidermal barrier dysfunc-
tion (Ashida et al., 2001). In addition,
nociceptin may stimulate the release of
leukotriene B4 from keratinocytes via
opioid receptor-like 1 receptor (Andoh
et al., 2004). Moreover, Miyamoto
et al. (2002) have shown that antago-
nists of opioid receptors suppressed
scratching behavior in a mouse model
of dry skin, most probably by a central
effect. In summary, dry skin induces
itch by stimulating the release of
various pruritogenic mediators from
keratinocytes. Less, however, is known
about the potential release of endogen-
ous antipruritogenic factors from kera-
tinocytes.
The MC–nerve connection: functions
beyond itch induction? The depicted
MC–nerve interactions may not only
promote but also terminate pruritus.
This yet unproven hypothesis is sup-
ported by several independent lines of
evidence (Figure S1). First, MCs express
and release large amounts of proteases
(tryptase, chymase, carboxypeptidase
A, and cathepsins), which have been
shown to degrade/inactivate prurito-
genic peptides. For example, MC
enzymes have been implicated to
downregulate axon reflex-mediated
neurogenic inflammation in skin and
other tissues by cleaving SP, CGRP,
and vasoactive intestinal polypeptide
(VIP). Also, MC chymases efficiently
degrade and terminate the activity of
endothelin-1 (ET-1) (Maurer, 2002).
ET-1 (a neuropeptide that is also
produced by, among others, endothe-
lial cells and MCs) has been implicated
in host defense against bacterial infec-
tions (Maurer, 2002) and cardiovascu-
lar diseases, and is known to induce a
burning and painful sensation as well
as itch upon injection into human skin
(Katugampola et al., 2000). Interest-
ingly, degradation of ET-1 by MC
chymase requires prior activation,
which is, at least in part, provided for
by ET-1 itself by binding to endothelin-
A receptors on MCs. In other words,
when ET-1 induces damage (e.g. prur-
itus), it also starts an ‘‘automatic self-
destruction program’’, that is, endo-
thelin-A-dependent release of ET-1-
degrading chymase from MCs. This
novel MC function may be relevant
for many skin conditions, in which
neuropeptides are implicated such as
atopic dermatitis or psoriasis.
Why is the degradation of neuro-
peptides by MC proteases a likely
mechanism of MC-mediated control
of pruritus? MCs undergo degranulation
and protease release in response to
several neuromediators including SP
and CGRP (Bienenstock et al., 1987).
However, processing of peptide med-
iators by MC proteases does not require
prior activation of MCs as some pro-
teases are constitutively expressed on
cell surfaces, thus allowing for contin-
uous regulation of neuropeptide levels
in the skin even in the absence of
MC-degranulating signals (Hagermark,
1974). In addition, MCs may also
contribute to the termination of neuro-
genic inflammation and pruritus by
regulating tissue expression of neutral
endopeptidases and angiotensin-con-
verting enzyme, two zinc metallo-
proteinases that effectively control
neuropeptide skin levels. Levels of
angiotensin-converting enzyme and
neutral endopeptidase in human skin
MCs were found to be increased in
response to various proinflammatory
mediators that are produced by MCs.
Interestingly, those proinflammatory
mediators, particularly tumor necrosis
factor alpha (TNF-a), are also known to
downregulate the expression of recep-
tors for SP and corticotropin-releasing
hormone (CRH). Thus, MC-derived
mediators could also limit pruritus at
sites of inflammation by increasing the
clearance of neuropeptides via neutral
endopeptidases and/or angiotensin-
M Steinhoff et al.
Basis of Pruritus
converting enzyme and by reducing
the numbers of their binding sites.
Finally, several independent studies
using MC-deficient animals have
shown that the frequency and/or dura-
tion of scratching in response to itch-
inducing agents are not reduced in the
absence of MCs (Hayashi et al., 2001).
On the contrary, pruritus appears to be
similar to or even stronger in geneti-
cally MC-deficient KitW/KitW-v mice
than in normal mice. For example,
KitW/KitW-v mice exhibit a 20% in-
crease in scratching behavior induced
by histamine or SP as compared to
normal Kit þ / þ mice (Hossen et al.,
2003 and references therein), and both
the time and the incidence of scratch-
ing responses induced by intracuta-
neous injections of compound 48/80
exceeded those of Kit þ / þ mice
(Inagaki et al., 2002).
Taken together, these findings sug-
gest that MCs can be involved both
in the activation as well as termination
of pruritus. The use of novel mouse
models including techniques to surgi-
cally denervate defined skin areas
as well as mice deficient for neuro-
peptides, neuropeptide-degrading pro-
teases, and/or MCs will help to clarify
these important questions.
NEUROPEPTIDES, NEUROTROPHINS
AND RECEPTORS
Tachykinins: ‘‘the MC connection’’
One of the best – albeit probably not
most important – neuromediators stu-
died thus far is SP (Table 1). Upon
stimulation by exogenous or endogen-
ous trigger factors, the above intro-
duced slow-conducting histamine-
sensitive C-fibers are not only capable
of transporting the itch signal to the
central nervous system (orthodromic)
but also release neuropeptides such as
SP and CGRP (antidromic). Because of
their anatomical association to cuta-
neous nerves, MCs and their released
products appear to play an important
role in the pathophysiology of itch
and inflammation (Steinhoff et al.,
2003a, b). Independent of neurokinin-1
receptor, intradermal application of SP
releases histamine from MCs, which
acts as a pruritogen (Thomsen et al.,
2002). Moreover, SP enhances intra-
www.jidonline.org 1711
 M Steinhoff et al.
Basis of Pruritus
dermal concentrations of nitric oxide,
which may enhance SP-induced prur-
itus (Andoh and Kuraishi, 2003). Spe-
cific neurokinin-1 receptor effects of SP
on MCs include TNF upregulation,
which in turn can sensitize pruriceptive
afferent endings.
Therefore, it is apparent that various
neuropeptides may exert indirect ef-
fects on sensory nerves by triggering
the release of pruritic agents from
various target cells such as MCs (hista-
mine, tryptase, chymase, TNF-a), en-
dothelial cells (kinins, endothelin),
keratinocytes (prostanoids, NGF), and
immune cells (cytokines). This me-
chanism is probably the main cause
for itch in atopic dermatitis, psoriasis,
and prurigo nodularis (Ständer et al.,
2003).
In the past, it was believed that MC
activation was all-or-nothing, with IgE
cross-linking inducing the functional
consequences of allergic reactions and
anaphylaxis. However, the activity of
MCs in health and disease is clearly
much more complex. Using the patch-
clamp technique, Janiszewski et al.
(1994) reported that MCs do not
respond electrophysiologically to very
low (picomolar) concentrations of SP,
but activation and delayed degranula-
tion occurred after a second exposure.
Therefore, MCs can be primed when
exposed to physiologically relevant
low concentrations of SP, and lower
their thresholds to subsequent activa-
tion. Thus, if MCs are indeed primed
by SP exposure, it would enable a
subthreshold stimulus to initiate MC
activation (Figure S1). Furthermore,
secretion can occur without the
evidence of degranulation, and even
molecules stored within the same
granules can be released and secreted
in a discriminatory pattern. Of course,
this mechanism may also be true for
other mediators not studied thus far.
Opioids
Another group of neuropeptides, the
opioids, have been used as analgetic
agents for more than 2000 years. So far,
more than 20 endogenous analogs
have been described, which are sub-
divided into three classes (endorphins,
enkephalins, and dynorphins) and
1712 Journal of Investigative Dermatology (2006), Volume 126
exert their effects by triggering opioid
receptors (m, d, k, and orphan recep-
tors) (Table 1).
Peripheral effects. With respect to itch,
intradermally injected opioids activate
MCs by a non-receptor-mediated mec-
hanism. In contrast to morphine, the
highly potent m-opioid agonist, fentanyl
does not provoke any MC degranula-
tion, even at concentrations having
m-agonistic effects exceeding those of
morphine. Thus, one can conclude that
morphine-induced MC degranulation is
not mediated by m-opioid receptors. As
high local concentrations of opioids are
required to degranulate MCs, itch
induced by systemic administration in
therapeutic opioids doses is probably
not owing to peripheral MC degranula-
tion, but to central mechanisms. There
is also no evidence for direct neuronal
excitation by peripherally applied
opioids as potent opioid agonists, even
at high concentrations, do not provoke
itch (Blunk et al., 2004 and references
therin). Thus, the impact of the ob-
served increased expression of m-opioid
receptors in atopic dermatitis (Bigliardi-
Qi et al., 2005) is unclear. However,
according to the inhibitory effects of
neuronal m-opioid receptors, it would
be expected that their increased ex-
pression act antipruritic. Interestingly,
peripherally applied CBs suppress his-
tamine-induced pruritus, with inhibi-
tory CB receptors CB1 and CB2 being
found on skin nerves (Stander et al.,
2005). However, the inhibitory effects
of peripheral CBs have been suggested
to be – at least in part – mediated
by a secondary release of endogenous
opioids in the skin (Ibrahim et al.,
2005). Moreover, endogenous CBs,
such as anandamide, have also been
shown to activate TRPV1 receptors (see
below), which adds to the complex role
of CBs in the modulation of pruritus.
A very similar complex interaction has
been shown for nociceptin: it activates
the inhibitory opioid receptor-like 1
receptor, whereas the direct neuronal
effect on nociception appears to be
inhibitory. Additionally, the secondary
release of leukotriene B4 by nociceptin
in the skin provokes itch behavior
(Andoh et al., 2004).
Central effects. It is common experi-
ence that itch sensation can be reduced
by painful sensations caused by
scratching or by various painful (ther-
mal, mechanical, chemical) stimuli.
Cutaneous field stimulation has also
been successfully used to inhibit hista-
mine-induced itch for several hours in
a relatively large (20 cm in diameter)
area around a stimulated site suggest-
ing a central mode of action. Not only
is itch inhibited by enhanced input of
pain stimuli, but vice versa inhibition of
pain processing may reduce its inhibi-
tory effect, and thus enhance itch. This
phenomenon is particularly relevant to
spinally administered m-opioid receptor
agonists, which induce segmental an-
algesia often combined with segmental
pruritus (Onigbogi et al., 2000). This
mechanism might well account for the
antipruritic effect of m-opioid antago-
nists (nalmefene, naloxone, and nal-
trexone) observed in experimentally
evoked histamine-induced itch as
well as pruritus in different dermatoses
(Metze et al., 1999; Heyer et al., 2002).
This phenomenon is particularly rele-
vant to spinally administered m-opioid
receptor agonists, which induce seg-
mental analgesia combined with a
naloxone-sensitive segmental pruritus
in about half of the patients.
Interestingly, while m-opioid recep-
tor antagonists significantly diminish
itch, in animal experiments, k-opioid
antagonists enhanced itch (Kamei
and Nagase, 2001). In line with these
results, the k-opioid agonist nalbuphine
as well as the new developed k-opioid
receptor agonist, TRK-820, have been
shown to reduce pruritus. As m- as well
as d-opioid receptors are expressed
by cutaneous nerve fibers, a crucial
role of opioids in the modulation of
itching can be expected.
Kinins, kallikreins
Pruritic activity of kinins has also been
investigated decades ago (Table 1). It
was shown that both the tryptic en-
zymes (such as kallikreins) and the
resulting peptide fragments (like the
mainly pain-inducing bradykinin) can
induce itch by activating histamine-
sensitive C-fibers (Schmelz et al.,
2003). Furthermore, there is some

evidence that bradykinin type-2 recep-
tor antagonists can reduce deoxycholic
acid-induced itch behavior in rodents
(Hayashi and Majima, 1999). More-
over, in this model, inhibition of tissue
kallikrein suppressed the itch indicat-
ing a major role for epidermal kallik-
rein during itch responses. Recent
studies on itch mediators mainly focus
on the role of proteases in pruritus (see
also in the following chapters): in-
creased kallikrein activity and reduced
kininogen levels were found in pruritic
popular eruptions. It is noteworthy that
intracutaneous injections of kallikrein
did not provoke marked itch in rats.
However, massive itch behavior is
observed in mice overexpressing epi-
dermal kallikrein-7 (Ny and Egelrud,
2004 and references therein).
Other neuropeptides and neurotrophins
Several mediators from the central
and peripheral nervous system, which
are involved in neuroimmune and
neuroendocrine interactions (Steinhoff
et al., 2003a, b and references therein).
Some of these mediators have been
implicated in the pathophysiology of
pruritus (Table 1). For example, CGRP
modulates inflammation and pruritus
(Brain and Grant, 2004), and prolongs
itch latency following SP injection
suggesting an inhibitory effect of
CGRP on SP-induced itching. How-
ever, increased amounts of CGRP
were observed in nerve fibers of
pruritic diseases such as atopic derma-
titis, nummular eczema, and prurigo
nodularis.
Intradermal application of vasoac-
tive intestinal polypeptide, neurotensin,
and secretin also led to a histamine-
dependent itch response, associated
with pruritus, whealing, and axon-
reflex erythema. In normal human
skin, vasoactive intestinal polypeptide
showed a comparable potency with
respect to pruritus as compared to SP.
Moreover, pituitary adenylate cyclase-
activating polypeptide, somatostatin,
and CRH were demonstrated to stimu-
late histamine release and MC degra-
nulation from human and rat skin
(reviewed in Steinhoff et al., 2003a, b
and references therein). CRH is well
known as an important neuroendocrine
mediator involved in stress response,
thereby modulating inflammation,
immunity, and pruritus. For example,
it was shown that CRH triggers
release of several mediator involved
in itch response (Lytinas et al., 2003),
possibly via CRH-R1 (Cao et al., 2005)
(Table 1).
Neurotrophins such as NGF and
neurotrophin-4 have also been impli-
cated in itch pathophysiology. NGF is
released by keratinocytes, MCs, and
fibroblasts (Groneberg et al., 2005).
Activation of its high-affinity receptor
(trk A) on sensory nerves leads to nerve
sprouting and sensitization. Serum
levels of NGF are increased in atopic
dermatitis patients, which induces
release of the pruritogenic mediator
tryptase (Groneberg et al., 2005). Also,
MCs and keratinocytes of these patients
generate high levels of NGF, which can
be stimulated by histamine (Kanda and
Watanabe, 2003). Similarly, neuro-
trophin-4 levels were also found to
be enhanced in atopic dermatitis
(Grewe et al., 2000), and brain-
derived neurotrophic factor (BDNF)
induces chemotaxis of eosinophils of
these patients (Raap et al., 2005).
Together, these results are clearly in
favor of an important role of neuro-
trophins in the pathophysiology of
itching, although direct evidence is still
lacking.
Proteases and their receptors
Another intriguing pruritogenic candi-
dates are the proteases. These mole-
cules comprise about 5% of the human
genome making them the largest pro-
tein family within the human being.
Classically, proteases are still regarded
as destructive enzymes, which break
down proteins or merely activate or
inactivate peptides by processing mole-
cules. However, little is known about
the role of proteases as signaling
molecules during neuronal transmis-
sion. Already in the 1950s, proteases
have been suggested to be ultimately
involved in itch responses, burning,
pain, and inflammation. Arthur and
Shelley, and later Rajka demonstrated
that exogenous as well as endogenous
serine proteases are capable of indu-
cing pruritus (Bodo et al., 2005 and
M Steinhoff et al.
Basis of Pruritus
references therein) (Figure 2, Table 1).
Trypsin and MC chymase provoke
itching and visible changes (edema,
flare) when injected intracutaneously,
at least in part via MC activation. In
contrast, papain-induced pruritus
seems to be histamine-independent.
A milestone in our understanding of
protease-mediated signaling was the
cloning of the first proteinase-activated
receptor, PAR1. Although PAR1, PAR2,
and PAR4 have been described in
neurons, a role of PARs in the patho-
physiology of itching has only been
shown for PAR2 (Vergnolle et al.,
2003). Importantly, functional PAR2 is
present on primary spinal afferents, and
releases neuropeptides upon stimula-
tion by tryptase (Steinhoff et al., 2000,
2003a, b, 2005). From this observation,
one may speculate that proteinases
activate PAR2 on sensory neurons,
thereby triggering pruritus in skin dis-
eases such as atopic dermatitis. Addi-
tionally, keratinocyte-derived PAR2,
which is upregulated in the epidermis
of atopic dermatitis patients (Budden-
kotte et al., 2005) may mediate pruritus
induced by endogenous (trypsins, kal-
likreins) or exogenous proteases (bac-
teria, house-dust mite). Indeed, in
atopic dermatitis patients, the endogen-
ous PAR2 agonist tryptase was in-
creased up to four-fold and PAR2
expression was markedly enhanced on
primary afferent nerve fibers of lesional
skin. In contrast, no significant differ-
ences in histamine concentrations were
observed between the diseased and
healthy samples, suggesting that tryp-
tase might be more important than
histamine for the transmission of itch
responses in atopic dermatitis. More-
over, intracutaneous injection of spe-
cific PAR2 agonists provoked sustained
and prolonged itch in such patients.
This observation may also explain why
non-sedative antihistamines are poorly
effective in atopic dermatitis. Thus,
PAR2 activation on cutaneous sensory
nerves and keratinocytes may be a
novel pathway for the transmission of
itch responses during atopic dermatitis
and probably other skin diseases.
Hence, PAR2 antagonists or protease
inhibitors may be promising therapeu-
tic targets for the treatment of pruritus
(Figure 2).
www.jidonline.org 1713
 M Steinhoff et al.
Basis of Pruritus
The TRP channel family in itch
Recent findings suggest that itch med-
iators exert their effects also by activat-
ing ion channels of the TRP channel
family. TRP channels comprise six
groups of molecules: the canonical
(TRPC), the vanilloid (TRPV), the mela-
statin (TRPM), the polycystin (TRPP),
and mucolipin (TRPML) subfamilies,
and the anhyrin (TRPA). In general,
these molecules act as calcium-perme-
able sensory transduction channels to
detect, for example, taste, warmth,
heat, cold, and osmotic/mechanical
stress both at cellular and multicellular
(i.e., whole organism) levels (reviewed
in Zhang et al., 2003 and references
therein). With respect to the develop-
ment and, most intriguingly, therapy of
itch, recently certain temperature-sen-
sitive members of the TRPV subfamily
and the TRPM8 gained substantial
interest (Figures 1 and 2; Tables 2 and S1).
TRPV1: a putative central role in the
pathogenesis and therapy of itch.
TRPV1 was originally described on
C-type nociceptive sensory neurons
(Caterina et al., 1997) as a molecular
target for capsaicin, the pungent in-
gredient of hot chili peppers. The
activation of the receptor first excites
these neurons by initiating ionic fluxes
and concomitant action potential firing
and neuropeptide release. At higher
doses and longer times, capsaicin
induces the desensitization the sensory
afferents (Caterina and Julius, 2001 and
references therein).
In addition to capsaicin, TRPV1 can
also be activated/sensitized by numer-
ous endogenous substances collec-
tively referred to as ‘‘endovanilloids’’
(Table 2). The receptor was first shown
to be stimulated by low threshold
(4431C), heat and acidosis. Later,
several other molecules were also
described to either directly and/or
indirectly act on the TRPV1. These
agents are, for example, eicosanoids,
bradykinin, prostaglandins, and various
neurotrophins (such as NGF, neurotro-
phin-3 and -4) (Lazar et al., 2004 and
references therein). It was also shown
that histamine-induced excitation of
sensory neurons and PAR2 activation
(Amadesi et al., 2004) does involve
the activation/sensitization of TRPV1.
1714 Journal of Investigative Dermatology (2006), Volume 126
Taken together, these findings strongly
implicate that TRPV1 is indeed a
central integrator molecule in the pain
and itch pathway.
Prolonged or repeated vanilloid ap-
plication results in a depletion of
neuropeptides such as SP in C-type
neurons, hence suspending the inter-
play between skin sensory neurons and
MCs. Indeed, topical capsaicin effec-
tively prevented histamine-induced
itch under experimental conditions. In
addition, capsaicin is widely used in
the therapy of pruritus in numerous
skin diseases such as prurigo nodularis,
notalgia paresthetica, pruritus ani, he-
modialysis-related pruritus, uremic
pruritus, etc. (Biro et al., 1997; re-
viewed in Yosipovitch et al., 2003).
Furthermore, recent findings provide
a new ‘‘hot’’ twist to the field further
highlighting the pathophysiological
and therapeutic importance of TRPV1
signaling in itch. Namely, functional
TRPV1 channels were described on
numerous non-neuronal cells types
including, of greatest importance, hu-
man skin epidermal keratinocytes, der-
mal MCs, dendritic cells, and various
keratinocyte populations of the hair
follicle (Bodo et al., 2005 and refer-
ences therein). In addition, activation
of TRPV1 – beside markedly affecting
proliferation, differentiation, and apop-
tosis – resulted in the upregulation of IL-
1b and tumor growth factor-b, whereas
IGF and HGF were downregulated in
the non-neuronal cells (Bodo et al.,
2005 and references therein).
These novel results invite an attrac-
tive hypothesis with further potential
therapeutic implications (Figures 1 and
3; Tables 2 and S1). Namely, topically
applied capsaicin may not exclusively
target sensory neurons but also TRPV1-
expressing MCs and keratinocytes,
thereby modulating the proposed neu-
ronal–non-neuronal network. We do
not know the complete pattern of
mediator changes following TRPV1
stimulation on non-neuronal cells.
However, TRPV1 expression was dra-
matically increased in epidermal kera-
tinocytes of prurigo nodularis patients
and normalized after successfully treat-
ing the characteristic nodular pruritic
lesions with topical capsaicin (Stander
et al., 2004). This example strongly
suggests a major role of TRPV1 expres-
sion in non-neuronal cells in pruritus
patients.
TRPV2, TRPV3, and TRPV4: further
intriguing targets to be investigated.
Originally, these channels were also
described as cellular temperature sen-
sor molecules as all are activated by
increasing temperatures (4531C for
TRPV2; 4311C for TRPV3; and
4251C for TRPV4) (Peier et al.,
2002b and references therein) (Table 2).
Importantly, TRPV3 exerts a very simi-
lar neuronal expression pattern to that
of TRPV1. In addition, it was also
postulated that TRPV3 subunits might
form heteromultimeric structures by
interacting with TRPV1 monomers
and therefore may act as signal co-
transducers and/or regulators of the
TRPV1-mediated pain and itch sensa-
tion. Indeed, mice lacking the TRPV3
have strong deficits in response to both
innocuous (mostly TRPV3 range) and
noxious heat (rather TRPV1 range)
(Moqrich et al., 2005).
Most intriguingly, functional TRPV3
and TRPV4 channels (similarly to
TRPV1) are also expressed at high
levels on epidermal keratinocytes (Pe-
ier et al., 2002b and references therein;
Moqrich et al., 2005). In addition,
TRPV4 was shown to be activated by
such lipid peroxidation products as
eicosanoids, which may also function
as TRPV1-activating pruritogenic sub-
stances (Watanabe et al., 2003). Thus,
sensitization and activation of TRP
channels could underly pruritic activity
of prostanoids and adding to their
complex role in pruritus induction.
Finally, with respect to the central
involvement of MCs in the initiation of
itch, it is worth noting that TRPV2 and
TRPV4 (along with TRPV1) are also
expressed by MCs (Stokes et al., 2004).
These authors also revealed that physi-
cal and thermal activation of TRPV2 on
MCs resulted in a proinflammatory
degranulation event, which depended
on the activity of the protein kinase A-
related signaling, one of the chief
mechanisms in initiating sensitization
of TRPV1 (a key event in initiating itch
and pain, see above) as well.
Although more studies are necessary
to further define the itch-related ‘‘non-

Initiation of itch
TRPV1
Specific
receptors
Pruritogenic
substances
(histamine,
neuropeptides,
kinins, etc.)
Specific
receptors
TRPV1
Figure 3. The proposed dual action of capsaicin to terminate itch. Pruritogenic substances either
directly (via their specific receptors) or indirectly (via activation/sensitization of TRPV1) stimulate sensory
neurons and non-neuronal cell types (MCs, keratinocytes) of the skin to initiate itch (left part in blue
frame). Topically applied capsaicin may not exclusively target sensory neuron-specific TRPV1 and hence
deplete the neuropeptide content but also act on TRPV1-expressing MCs and keratinocytes, and, in turn,
significantly alter the proposed neuronal–non-neuronal interaction network to terminate itch (right part in
red frame).
thermosensor’’ role of these channels
(e.g. in keratinocyte-specific cytokine
and mediator synthesis and release),
the close resemblance to TRPV1 with
respect to cell-specific expression, ac-
tivation, sensitization, and to the in-
itiated cellular mechanisms highlights
their putative roles in itch pathophy-
siology.
Icilin and the ‘‘cool’’ TRPM8 channel.
Another intriguing member of the TRP
family is TRPM8, which is selectively
expressed in C-type sensory neurons
(Figures 1 and 3; Tables 2 and S1).
TRPM8 is thought to be a thermosensor
for coolness and cold (8–281C) and also
activated by chemicals – menthol,
menthol analogs, and icilin – which
Terminiation of itch
TRPV1
Sensory nerve
endings
Capsaicin
TRPV1
Non-neuronal
skin cells
produce sensations of cold (Peier et al.,
2002a and references therein).
Icilin was first synthesized with the
intent of finding a morphine-like an-
algesic, but when tested in rodents it
produced unusual behavioral events.
Icilin injected into the systemic circula-
tion of fur-coated animals produces
rotational movements similar to those
manifested by a dog when wet (‘‘wet
dog shakes’’). Icilin initiates punctate
sensations of coolness, harmonizing
with the idea of ‘‘cold spots’’, when
the particles come into contact with
the various mucosal surfaces (Wei and
Seid, 1983). Icilin was compared to
menthol and, for in vivo effects such as
‘‘wet shake behavior’’, it was 400 
more active than menthol. Unlike
M Steinhoff et al.
Basis of Pruritus
menthol, it did not smell or irritate the
eyes.
Comparisons continued after the
cloning of TRPM8 with calcium entry
into cells as an index of activity. The
EC50 of icilin in TRPM8-transfected
cells was reported to be 200  to
800  less than menthol, but potencies
of the two cannot be directly matched
because the maximum efficacy of icilin
for calcium entry was greater than that
of menthol. Icilin also activates TRPA1
(ANKM1), another TRP channel, but at
a lower potency than TRPM8.
In an animal model of scratching
in hairless rats, provoked by a magne-
sium-deficient diet, a 2% icilin oint-
ment reduced the degree of excoria-
tions by 55–60% (E Wei and Meingass-
ner T, unpublished data). In this model,
it was found that 2–3% icilin ointment,
elicited robust cooling sensations for
2–4 h without any irritancy. The onset
of maximal cooling occurred within
10–15 minutes after application.
The TRPM8 agonist menthol and
analogs were also examined (Behrendt
et al., 2004). The most active analogs
were comparable in activity to
()menthol and at least 16-fold less
active than icilin, with lower maximal
responses. Carboxamides exert activity
similar to icilin on TRPM8 in vitro.
When applied to the skin, carboxa-
mides produce cold sensations lasting
from 30 minutes to 1 hour. Thus, car-
bocamides may serve as a model
for endogenous TRPM8 agonists. Thus,
with the identification of TRPM8 (and
TRPA1) (Table 2) and the novel chemi-
cal ligands for these ion channels,
understanding the linkage of psychic
and somatic (e.g. dry skin, temperature
changes) adjuncts of skin discomfort to
molecular, cellular, and sensory inputs
now seems more exact. Ultimately, the
proposed mechanisms of chemical ac-
tion will have to be resolved by further
tests in human subjects.
Cytokines, IFNs
Recent findings clearly indicate a
direct role of cytokines and chemo-
kines on the regulation of primary
afferent neurons via receptor activation
(Steinhoff et al., 2003a, b and refer-
ences therein; Dillon et al., 2004)
(Figures 1 and 2 and S1).
www.jidonline.org 1715
 M Steinhoff et al.
Basis of Pruritus
IL-2. Clinical observations suggest a
role of IL-2 as an inducer of pruritus.
High doses of recombinant IL-2, ap-
plied to cancer patients, for example,
are capable of provoking flush, vasodi-
latation, and pruritus. Whether this
is a direct, receptor-mediated process
or an indirect, for example, via MCs
or endothelial cells, is still unknown.
Accordingly, treatment of Alzheimer
disease (AD) patients with systemic or
topical immunosuppressants such as
tacrolimus, pimecrolimus, or cyclos-
porin A, for example, which inhibit the
production of various cytokines includ-
ing IL-2, experience attenuation of
pruritus.
Another mechanism of action with
respect to cytokine-induced itch may
be synergistic amplification or receptor
transactivation. For example, bradyki-
nin appears to augment the effect of IL-
2-induced pruritus on sensory nerves.
However, the latency preceding the
itch response after injection in AD
patients suggests an indirect prurito-
genic effect of IL-2 via other mediators.
IL-8. Recent observations suggested a
role of IL-8 as a mediator of itch in AD
patients. However, intracutaneous ap-
plication of IL-8 was not sufficient to
induce pruritus or erythema in human
skin (Stander and Steinhoff, 2002 and
references therein).
IL-31. IL-31 is a novel cytokine pre-
ferentially produced by T-helper type 2
cells, which induces both severe prur-
ititis and dermatitis in mice. Dillon
et al. (2004) recently demonstrated that
transgenic overexpression of the novel
cytokine IL-31 in T-lymphocytes in-
duces severe pruritus and dermatitis in
mice. IL-31 signals via a heterodimeric
receptor composed of IL-31 receptor A
and the oncostatin M receptor.
Whether IL-31 exerts its effects via
direct activation of the IL-31R on
sensory nerves or indirectly, for exam-
ple, via keratinocytes is unknown. The
finding that keratinocytes express the
IL-31 R suggests that IL-31 may induce
pruritus through the induction of a yet
unknown keratinocyte-derived media-
tor, which subsequently activates un-
myelinated C fibers in the skin. From
1716 Journal of Investigative Dermatology (2006), Volume 126
these observations, it is intriguing to
speculate that IL-31 is upregulated in
pruritic but not in non-pruritic forms of
chronic skin inflammation. Thus, IL-31
may be a new link between the
immune and nerval system by regulat-
ing inflammation as well as itch. This
may also suggest that IL-31 and its
signaling pathway represent a novel
target for antipruritic therapy (Sonkoly
et al., 2006).
INF-g. In a double-blind study, a
beneficial effect of IFN-g on itch
responses has been clearly demon-
strated also in AD patients. Pruritus
was reduced by 50% even 1–2 years
after long-term treatment with recom-
binant human IFN-g. However, the
mode of action and the receptor
density of IFN receptors on sensory
nerves in the skin is unknown.
Summary and perspectives
Itch research not only has proposed a
variety of potential itch mediators but
also identified non-neuronal cells con-
tributing to the pathophysiology of
pruritus. Being confronted with a
variety of potential pruritic mediators
generated by close interaction of neu-
ronal and non-neuronal cells three
major directions for future research
arise:
First – which is the crucial pruritic
mediator in a particular skin disease
and how can it be modulated/sup-
pressed? Second – what is the basis for
an inflammatory process to release itch
mediators and sensitize itch receptors
rather than to produce pain and sensi-
tization to pain? Third, which mechan-
isms can be used to modulate neuronal
itch processing in the periphery, the
spinal cord, and the central nervous
system? The insight in anatomical and
physiological structures as provided by
central imaging will help to identify the
involved central areas. Consequently,
both, animal studies and clinical trials
will further dissect the interaction and
communication between the central
and the peripheral nervous system
under physiological and pathophysio-
logical conditions. Here also, novel
molecular imaging approaches may
help to better understand the complex-
ity within the central nervous system
when processing itch information.
With respect to novel therapies, the
potential redundancy of many pruritic
signals complicates specific treatment
(Figure 3, Table S1). Thus, it will be a
major task to identify convergent per-
ipheral and central targets in the itch
pathway to increase the chances of
clinical success.
Therefore, future research will have
to clarify underlying mechanisms that
induce, modulate, and transmit the itch
signal on a molecular level to finally
identify the essential molecules as
targets for antipruritic therapy. More-
over, understanding perception and
regulation of itch signals within the
central nervous system will lead to
novel strategies for the treatment of
pruritus.
CONFLICT OF INTEREST
The authors state no conflict of interest.
ACKNOWLEDGMENTS
This work was supported by grants from the IZKF
Münster, SFB 492, SFB 293, DFG (STE 1014/2-1),
Serono Germany, CE.R.I.E.S. Paris, and Rosacea
foundation (to M.S.). Owing to limited space for
references, an adequate version of important
references can be looked up in the supplement.
SUPPLEMENTARY MATERIAL
Supplementary References.
Figure S1. Hypothetic mechanisms of mast cell
functions in the control of pruritus.
Table S1. Established therapies of itch and
experimental strategies.
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