Shawn Kwatra, MD, with John Jesitus
The dearth of data regarding topical cannabinoids in dermatology leads to a lack of confidence for prescribers. In this climate, experts recommend using FDA-approved treatments when possible, and, when needed, sticking to cannabinoids that have the most data behind them.
“Topical cannabinoids are an exciting new potential therapeutic option for dermatology patients,” said Shawn Kwatra, MD. “Studies have shown tremendous anti-inflammatory properties of cannabinoids, particularly in itch, atopic dermatitis, and other inflammatory skin conditions.” Dr. Kwatra is Assistant Professor of Dermatology at Johns Hopkins University, Baltimore, Maryland, and Director of the Johns Hopkins Itch Center.
But with no drugs specifically FDA-approved for itch, he said, treating this symptom can be extremely difficult. “We are forced to manage patients primarily with off-label therapies. If a patient fails classic first-line dermatological therapies like topical steroids and there are no other approved therapies available, it may make sense to try experimental or compounded therapies.”
Patients are increasingly interested in topical cannabinoids, he added. “But if we don’t have great studies showing what is the right patient population, what is the right dosing, and how to monitor for side effects, it’s very difficult for clinicians to give their full approval.”
Accordingly, Dr. Kwatra said that for conditions with on-label, FDA-approved treatments, “it makes sense to try those agents first. But if a patient is uncontrolled and the disease is impacting their quality of life, as an off-label therapy, I would try to pick products that have a little more data on them.” Among topical cannabinoids, he said, palmitoylethanolamide (PEA) compounds rank among the most thoroughly studied.1,2
Some researchers have expressed concern that the use of unregulated topical cannabinoids before or after dermatologic procedures could increase the risk for infection and possibly lead to systemic absorption and/or wound-healing difficulties.3 However, Dr. Kwatra said this is a hypothetical concern.
Marketplace concerns include misrepresentation of what topical cannabinoids can do. Adam Friedman, MD, said, “Cannabinoids offer a fleet of possible new therapeutics. But you have to be science-driven. I worry that people will make outrageous and erroneous claims that can lead people down a dangerous path of not seeking proper medical care and relying on a ‘natural’ product that has no evidence supporting its use.” Dr. Friedman is Professor and Interim Chairman of Dermatology at George Washington School of Medicine and Health Sciences in Washington, DC.
Just because a product is natural, he added, does not necessarily mean it is safe or effective. Allergic reactions to excipients used in cannabidiol (CBD) oils and creams have been reported. CBD is essentially safe, said Dr. Friedman, but one must ask, “What else is in the product?” Small manufacturers that have sprung up virtually overnight typically lack the capital and expertise to ensure that their products do not contain irritants or allergens, he said.
Allergic reactions to topical cannabinoids and vehicle ingredients may occur, said Dr. Kwatra. The most common side effects are redness and stinging, which is why he said it’s always a good idea to do a test spot before applying to a larger body surface area. Weighing the risks and benefits, he added, this may be a small price to pay compared to topical cannabinoids’ potential benefits.
References
1. Avila C, Massick S, Kaffenberger BH, Kwatra SG, Bechtel M. Cannabinoids for the treatment of chronic pruritus: a review. J Am Acad Dermatol. 2020;82(5):1205-1212.
2. Khanna R, Khanna R, Denny G, Kwatra SG. Cannabinoids for the treatment of chronic refractory pruritus. J Dermatolog Treat. 2021;32(2):266-267.
3. Hashim PW, Cohen JL, Pompei DT, Goldenberg G. Topical cannabinoids in dermatology. Cutis. 2017;100(1):50-52.
Disclosures
Dr. Kwatra reports no relevant financial interests.
Dr. Friedman is a consultant and/or advisory board member for Corbus Pharmaceuticals Holdings, Greenway Therapeutix, Hoth Therapeutics, TruPotency, and Zylo Therapeutics.