Medical marijuana can alleviate pain, anxiety associated with skin disease

Key takeaways:

• Dermatologists are encountering more patients requesting recommendations for medical marijuana.
• Adam Friedman, MD, FAAD, discusses the benefits and risks of making one such recommendation.

Patients are growing increasingly interested in medical marijuana. As this interest grows, dermatologists must be prepared to navigate the ethical, legal and scientific complexities of its use, according to an expert.

This preparation includes understanding the benefits, risks and uses of medical marijuana for patients with skin disease.

“Medical marijuana is an increasingly common therapy that patients turn to for relief from chronic pain, inflammation and anxiety,” Adam Friedman, MD, FAAD, professor and chair of dermatology at George Washington University School of Medicine & Health Sciences and a member of Healio Dermatology’s Peer Perspective Board, told Healio. “All of which are symptoms often seen in dermatologic conditions like atopic dermatitis and hidradenitis suppurativa.”

In a letter written to the Journal of the American Academy of Dermatology’s Ethics Journal Club in December 2024, a concerned provider relayed an encounter with a patient who was requesting a recommendation for medical marijuana.

“I am managing a patient with HS who uses marijuana regularly to manage her pain and anxiety,” the letter read. “She claims it provides significant relief and has requested that I recommend her marijuana use as medically necessary, so that she may fly with it on vacation and carry it across state lines.”

Due to varied state laws, the provider expressed discomfort in making the recommendation. The Ethics Journal Club published a response, acknowledging the benefits of marijuana use for the management of HS and other indications, but ultimately advised the dermatologist to suggest an alternative pain management option to the patient because the current legal and research landscape does not support such a recommendation.

Healio spoke with Friedman, who has previously led research on this topic, about the dermatologic use of medical marijuana.

Healio: What are the benefits of using medical marijuana in dermatology?

Friedman: Cannabinoids — particularly cannabidiol (CBD) and tetrahydrocannabinol (THC) — interact with the body’s endocannabinoid system, which plays a role in regulating inflammation, immune response, pain and skin barrier function. Topical and systemic cannabinoids may reduce inflammation, alleviate pruritus and modulate pain.

What we know from a preclinical perspective is that activation of the endocannabinoid system in the skin reduces inflammation through a number of mechanisms, such as shifting the proinflammatory response to an anti-inflammatory response via cannabinoid receptor 2r activation . The endocannabinoid system also plays a role in regulating keratinocyte proliferation and maturation, which are dysfunctional in aged skin and pathologically increased in diseases like psoriasis.

For example, cannabinoid receptor 1r activation by cannabinoids such as anandamide inhibits keratinocyte differentiation and decreases production of keratin K6, a marker of keratinocyte hyperproliferation. The potential anti-inflammatory effects of CBD may also include activation of noncannabinoid receptors such as G protein-coupled receptor 55, which reduces inflammation caused by nerve growth factor, and peroxisome proliferator-activated receptor alpha and beta, which reduces skin thickening via suppressed proliferation of keratinocytes.

One of the most compelling pieces of emerging clinical evidence, and yes I am biased, comes from our recent clinical trial published in the Journal of the American Academy of Dermatology, which evaluated the effects of a topical nanoencapsulated CBD cream (CielementsMD) on ultraviolet-induced skin damage in human volunteers.

This study is one of the first clinical trials to demonstrate biologic protection against photo-induced molecular skin damage in vivo using a cannabinoid-based therapy. Although the population was healthy and not disease specific, the results suggest therapeutic potential for chronic inflammatory skin diseases in which oxidative stress plays a role, such as AD, psoriasis and even HS.

However, we don’t have great data on the pain-inhibiting capacity because most of the research was done in animals. Applying too much CBD is probably not an issue, short of anyone who has a sensitivity to CBD or the ingredients in the vehicle. The side effects we know of are mostly from oral intake.

It has been noted, and I have seen this in my own practice, that patients with HS, for example, have reported decreased pain and anxiety with the use of cannabinoids.

Healio: What are the risks?

Friedman: Systemic marijuana use is not without consequences. There are potential long-term risks, including dependency, cognitive impairment and worsening of psychiatric conditions, such as anxiety, depression and suicidal ideation.

Fortunately, for CBD, we have an FDA-approved drug derived from it called Epidolex (cannabidiol) and, therefore, have a strong understanding of its safety through the clinical trial path to approval. For example, signals of liver toxicity only emerged when about 1.5 g of CBD per day was used, which is a lot.

I also think topical applications could be a great compromise if delivered purposefully. One of the major limitations with delivering THC or CBD or both through the skin is just that — they are poorly soluble and have a real penchant for fatty environments, so they don’t mix well with many delivery vehicles and they don’t penetrate the skin well.

To overcome this limitation, as alluded to earlier, my research group is using an innovative delivery system called nanoparticles to encapsulate endocannabinoids and CBD to better enable skin penetration and clinical success.

That said, product inconsistency is a risk with topical products. Many over-the-counter CBD products are mislabeled, contaminated or contain THC despite claiming not to. Moreover, without standardized formulations and regulated dosing, even topical products present variability in both efficacy and safety.

Healio: Which patients are good candidates for medical marijuana therapy?

Friedman: At this time, there is no dermatology-specific indication that would make any patient an ideal candidate for systemic medical marijuana, although I believe there are many examples for which it would be appropriate.

However, some patients with severe, refractory symptoms who have not responded to traditional therapies may choose to explore marijuana independently. In such cases, our ethical responsibility is to ensure they are fully informed of the risks and benefits.

Healio: Should medical marijuana be used in dermatology?

Friedman: Absolutely — but we need more robust, dermatology-focused research before medical marijuana can be responsibly integrated into care.

A study we published with 504 participants found that 88.8% supported the use of medical cannabis for dermatologic diseases, with many already using over-the-counter cannabinoid products to manage conditions like acne, rosacea and psoriasis. So, patients are interested and we need to be ready to support them.

The law has changed rapidly, and as of this month, there are only four states in which any form of cannabis is fully illegal, so that is exciting. But like any medical technology, the evidence must support the claims and use.

Healio: If a dermatologist does not want to recommend medical marijuana because of safety concerns, what are alternative pain and anxiety management options?

Friedman: I have a different mindset in that I have been able to get patients off opioids with cannabis, which, in my opinion, is safer. The only reason not to recommend medical marijuana would be if one does not feel appropriately educated or comfortable with this space.

That said, there are several evidence-based alternatives for pain. Treatments like gabapentinoids, nonsteroidal anti-inflammatory drugs or certain antidepressants can be helpful. For anxiety, selective serotonin reuptake inhibitors, behavioral therapy and coordinated care with mental health professionals offer more reliable outcomes.

The goal is always to treat the whole patient while minimizing harm — something dermatologists probably can’t yet confidently achieve with medical marijuana yet, but we will get there.

For more information:

Adam Friedman, MD, FAAD, can be reached at dermatology@healio.com.

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