The therapeutic potential of cannabis in skin diseases

The endocannabinoid system of the skin plays an important role in various biological processes and is considered a promising target for a number of skin diseases, including acne, increased sebum production, atopic dermatitis, itching, psoriasis, and skin cancer. However, to date, no clinical trials have been conducted in this research area and only a few case reports have been published.

I would like to present four cases of various skin diseases from my practice in which cannabis therapy was very effective.

A 41-year-old man with hereditary hyperhidrosis (increased sweating) experienced severe side effects from standard pharmacological treatment and after surgery. A 42-year-old man with acne inversa had to undergo repeated abscess surgery in the perianal, perigenital, and inguinal regions every year before he started using cannabis in 2008.

A 33-year-old man had been suffering from psoriasis (psoriasis) since 2001 and was resistant to standard medications such as corticosteroids, methotrexate, and biologics.

A 74-year-old man suffered from recurrent basal cell carcinoma (basal cell carcinoma, white skin cancer) on his nose.

The endocannabinoid system of the skin

The endocannabinoid system of the skin plays an important role in various physiological processes, including growth, generation of various skin cells, apoptosis (programmed cell death), and production of various messenger substances. The main functions of this system are considered to be the control of growth, differentiation of various cell types and survival, and immune function of skin cells. Disruption of this balanced control can promote a variety of skin diseases, and affecting the endocannabinoid system can be an attractive target for treatment in disease. Some of my approved patients suffered from skin conditions, namely atopic dermatitis, pruritus, urticaria of unknown origin, hyperhidrosis (increased sweating), acne inversa, and psoriasis.

Case 1: Hyperhidrosis (excessive sweating)

A 41-year-old man with hereditary hyperhidrosis. The symptoms started during puberty and gradually increased. He suffered mainly from profuse sweating of the hands and armpits. At age 25, he began medical treatment, first with medications that were either ineffective or at high doses caused severe side effects, including vision problems, dry mouth, drowsiness, and balance problems. Finally, in 2009, he underwent two sessions of endoscopic surgery in his armpits. The hyperhidrosis in his armpits and hands subsequently disappeared, but he developed compensatory sweating in his abdomen, back, legs, and buttocks. He had used cannabis a few times in his youth. Two years prior to the visit to my office, he had tried the drug again after reading on an Internet forum that cannabis could reduce profuse sweating. He found that after inhaling cannabis flowers, the sweating stopped within minutes, lasting 2-3 hours. Since then, he has been able to have a normal social life. He also takes doxepin, which reduces night sweats. He requires 4 g of cannabis per day.

Case 2: Acne inversa

A 42-year-old man with acne inversa. In addition to acne inversa, he suffered from allergic asthma and a chronic pain syndrome in his back due to scoliosis and Scheuermann's disease. Since about 2002, he suffered from recurrent abscesses in the area of the anus, genitals and groin. The correct diagnosis was not made until 2013. Almost every year he had to undergo surgery with several weeks of absence from work. The name acne inversa is somewhat misleading because it is not acne, but a serious autoimmune disease. It often takes so long to diagnose because patients are presented to surgeons who only operate on the abscesses in question without understanding that it is a systemic disease. In 2008, he tried regular cannabis after a friend who suffered from atopic dermatitis that responded to the drug suggested a trial. My patient used low doses of cannabis of about 10g per month and was disease-free between 2008 and 2013. After a treatment-free hiatus in 2013, he relapsed. We started treatment with Sativex® and continued treatment with cannabis flower after he was approved by the Ministry of Health in August 2015. He currently consumes small amounts of cannabis every other day and increases the dose when he notices the first signs of recurrence.

Case 3: Psoriasis

A 33-year-old man with psoriasis. His first severe outbreak of psoriasis occurred more than 15 years ago. He consulted several dermatologists and tried a large number of medications, including methotrexate, dimethyl fumarate, corticosteroids, antihistamines, a variety of ointments and creams, and several biologics (infliximab, efalizumab, eternacept, adalimumab). All therapeutic measures were largely ineffective and many were associated with side effects. He first used cannabis at the age of 16 or 17. With the onset of psoriasis symptoms, he began to use it regularly. It did not have a strong effect on the severity of the disease. However, the course of the disease is positively influenced by the reduction of itching and scratching and improvement of sleep. Cannabis significantly improves his quality of life and ability to work.

Case 4: Basal cell carcinoma (white skin cancer)

A 74-year-old man with basal cell carcinoma and actinic keratosis. Both basal cell carcinoma and actinic keratoses are referred to as white skin cancer. Unlike black skin cancer, basal cell carcinoma very rarely forms daughter tumors (metastases). Actinic keratosis can develop into an aggressive squamous cell carcinoma of the skin. Basal cell carcinoma of the nose was first diagnosed in 2003 and treated with radiation in 2014. In 2006, a large-scale skin graft was performed on the nose. According to a February 2016 letter from the Department of Dermatology and Venereology at a university hospital, the basal cell carcinoma had recurred in two locations on his nose. He refused the surgery and made an appointment at my office. When I finally saw the patient, who also suffered from chronic pain and restless leg syndrome, the basal cell carcinomas on his nose had completely disappeared. In consultation with his dermatologist, he had been applying a small amount of THC-rich cannabis extract (hash oil) to the affected areas four times a day. Within two weeks, the lesions had healed. Complete healing of the actinic keratosis on his skull took four weeks.

Brief overview of cannabis for skin disorders

Several causes of primary or secondary hyperhidrosis or increased sweating have been proposed. As in the present case, there may be a hereditary background. Severe increased sweating can be observed after abstinence from cannabis and is a common side effect of treatment with THC. This may explain the therapeutic effect in the present case, probably by activation of the cannabinoids-1 receptor. As in the case presented here, acne inversa often does not begin until puberty and may be associated with other autoimmune diseases, in the present case Scheuermann's disease, which causes spinal discomfort. The effectiveness of pharmacological treatments (antibiotics, anti-inflammatory drugs such as TNF-alpha inhibitors) of acne inversa is limited. Therapy is usually surgery, sometimes with opening of individual abscesses, sometimes with extensive surgical procedures. Cannabinoids have been shown to affect skin cell differentiation, sebum-producing cell activity, and oil production. Both THC and CBD have anti-inflammatory properties and may be helpful in autoimmune diseases. Psoriasis is a chronic skin disease with increased formation of skin cells and scales, as well as inflammation, characterized by the upregulation of certain proteins (keratins K6 and K16). This can be reduced by substances that bind to the cannabinoid 1 receptor, such as THC. In addition, CB1 receptor agonists have been shown to downregulate mast cell activation in a mouse model of atopic dermatitis, which may explain the relief of inflammatory symptoms mediated by mast cell activation, such as atopic dermatitis, psoriasis, and contact dermatitis. Cannabinoids can be successfully absorbed through the skin, and both systemic and topical application of cannabinoids may be beneficial for the treatment of inflammatory skin conditions . There have been several other case reports published on the medicinal value of cannabis in psoriasis. There are also some case reports on the Internet about the successful treatment of basal cell carcinoma, also called basal cell carcinoma, by the topical application of cannabis extracts. In human melanoma cells (black skin cancer), the CB2 receptor has been found to be upregulated compared to normal skin tissue, and cannabinoids are considered by some scientists to be useful in the treatment of melanoma. Local administration of cannabinoids induced significant growth inhibition of non-melanoma skin cancers in experiments with nude mice. Cannabinoid-treated tumors showed increased programmed cell death and impaired blood flow to the tumors.

Conclusion

The endocannabinoid system may be a promising target for the treatment of a variety of serious skin conditions. Many patients have found, usually by chance or after internet research, that the use of cannabis may be helpful for their often otherwise treatment-resistant dermatologic conditions, including atopic dermatitis, psoriasis, pruritus, urticaria, hyperhidrosis, acne inversa, and skin cancer. To date, none of these indications have been the subject of clinical trials with cannabis, individual cannabinoids, or other modulators of the endocannabinoid system. Physicians should be aware that patients who experience significant improvement in these conditions with cannabis products are unlikely to be isolated cases and that these experiences have a biological basis. Dermatology is an under-studied but promising area for the use of cannabis in medicine.