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The Role of Cannabinoids in Dermatology

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The Role of Cannabinoids in Dermatology COMMENTARY The role of cannabinoids in dermatology Jessica S. Mounessa, BS,a,b Julia A. Siegel, BA,c Cory A. Dunnick, MD,a,b and Robert P. Dellavalle, MD, PhD, MSPHa,b Aurora and Denver, Colorado, and Worcester, Massachusetts Key words: cannabinoid; cannabis; dermatitis; endocannabinoid; inflammatory skin disease; keratinocyte carcinoma; melanoma; palmitoylethanolamide; pruritus; skin cancer; tetrahydrocannabinol. wenty-eight states currently allow for Abbreviations used: comprehensive public medical cannabis programs, and this number continues to CB1: cannabinoid 1 T1 CB2: cannabinoid 2 grow. Approximately 1 in 10 adult cannabis users in 2 PEA: palmitoylethanolamide the United States use it for medical purposes. THC: tetrahydrocannabinol Numerous studies have investigated its uses for chronic pain, spasticity, anorexia, and nausea. In recent years, researchers have also investigated its work independently of descending inhibitory use for the treatment of dermatologic conditions pathways.5 including pruritus, inflammatory skin disease, and Cannabinoids may also have anti-inflammatory skin cancer. properties useful for the treatment of both allergic Perhaps the most promising role for cannabinoids contact dermatitis and atopic dermatitis. Petrosino is in the treatment of itch. In a study of patients with et al6 reported that mice released PEA in response to uremic pruritus on maintenance hemodialysis, 2,4-dinitrofluorobenzeneeinduced allergic contact topical application of a cream with structured dermatitis as an endogenous protective agent. PEA physiologic lipids (derma membrane structure) and may work to reduce later stages of allergic contact endogenous cannabinoids applied twice daily for dermatitis, including mast-cell infiltration, angiogen- 3 weeks completely eliminated pruritus in 8 of 21 esis, and itching.7-9 Tetra-hydrocannabinol (THC) patients (38%). The authors suggested that the well- may also demonstrate anti-inflammatory effects 3 tolerated product might work by reducing xerosis. independent of CB1 and cannabinoid 2 (CB2) 4 Stander et al further studied 22 patients with pru- receptors. In mice, topical THC decreased rigo, lichen simplex, and pruritus who applied an allergic-contact ear swelling and inflammation in emollient cream with palmitoylethanolamide (PEA). both wild-type mice and mice lacking CB1 and CB2 PEA, which stimulates anandamide (endocannabi- receptors. Topical THC limited myeloid immune cell noid) activation of cannabinoid 1 (CB1) receptors, recruitment by a decreasing T-cell production of reduced itch by 86.4% and was well tolerated by interferon-g and keratinocyte production of CCL2, patients. Most recently, WIN 55,212-2, a cannabinoid CCL8, and CXL10 chemokines.9 In terms of atopic agonist, was found to reduce serotonin-induced dermatitis, the activation of CB1 receptors in mice itching in a dose-dependent manner through intra- has been found to improve epidermal barrier peritoneal administration in mice. When the inves- function, decrease Th2-mediated inflammatory tigators used neurotoxins to deplete serotonin in the response,10,11 and suppress mast cells.12 spinal cord, they reported no change in these results. Limited studies on its uses for other skin condi- Thus, they suggested that the cannabinoids may tions also exist. Cannabinoids may be useful for From the University of Colorado School of Medicine, Auroraa;VA Correspondence to: Robert P. Dellavalle, MD, PhD, MSPH, Denver Eastern Colorado Health Care System, Denverb; and the Veterans Affairs Medical Center, 1055 Clermont Street, Box 165, University of Massachusetts Medical School, Worcester.c Denver, CO 80220. E-mail: [email protected]. Ms Mounessa and Ms Siegel contributed equally to this article. Published online April 14, 2017. Funding sources: None. J Am Acad Dermatol 2017;77:188-90. Conflicts of interest: None declared. 0190-9622 Reprints not available from the authors. Published by Elsevier on behalf of the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2017.02.056 188 JAM ACAD DERMATOL Mounessa et al 189 VOLUME 77, NUMBER 1 Table I. Psychotropic activity of cannabinoids investigated in dermatology Weak/No psychotropic effects Cannabinoid Potential uses Cannabidiol (CBD) Psoriasis13 Cannabigerol (CBG) Psoriasis13 Palmitoylethanolamide (PEA)* Pruritus,4 allergic contact dermatitis,6-9 atopic dermatitis,25 other eczematous dermatoses,24 melanoma22 Psychotropic effects Cannabinoid Potential uses D 9-tetrahydrocannabinol (D9-THC) Allergic contact dermatitis,9 psoriasis,13 melanoma23 Cannabinol (CBN) Psoriasis13 *Not strictly considered an endocannabinoid; PEA does not bind to CB1 and CB2 receptors, but works by enhancing endocannabinoid binding to these receptors. psoriasis, as THC, cannabidiol, cannabinol, and cell apoptosis.18-20 Furthermore, CB1 and CB2 cannabigerol have been found to inhibit keratino- receptor activation in mouse melanoma and cyte proliferation in hyperproliferating human kera- melanoma cell lines decreased the proliferation, tinocyte cell lines.13 In mice, CB1 knockout mice angiogenesis, and metastasis of melanoma, perhaps were protected from bleomycin-induced fibrosis, through inhibition of the prosurvival protein Akt and and the selective CB1 receptor agonist N-(2- hypophosphorylation of the pRb.21 Anandamide, 2- chloroethyl)-5Z,8Z,11Z,14Z-eicosatetraenamide arachidonoylglycerol, and PEA diminished the was shown to promote bleomycin-induced fibrotic viability of murine melanoma cells. Cotreatment of effects. Tight skinÀ1 mice, characterized by an PEA with URB597 (a fatty acid amide hydrolase accumulation of collagen fibers in the hypodermis inhibitor) significantly increased cell death, and this and an absence of inflammatory infiltrates, were not effect was further observed in mice.22 Most recently, protected against fibrosis in CB1 knockout models. mice with chemically induced melanoma treated Thus, the authors suggested that the profibrotic with subcutaneously injected THC demonstrated effects of CB1 are mediated by the effects of CB1 significant inhibition of tumor growth. Mice deficient on leukocytes, and CB1 ablation may be used as a in CB1 and CB2 receptors still showed development potential treatment for the early inflammatory stages of chemically induced tumors, demonstrating that of scleroderma and systemic sclerosis.14 It is the endogenous cannabinoid system did not influ- important to note that other studies have ence the tumor growth.23 demonstrated beneficial antitumorigenic effects of These studies identify a relationship between cannabinoid activation (see next paragraph),15 cannabinoids and the immune system through which were not mentioned in this study. both receptor-mediated and receptor-independent Furthermore, in a recent single-blinded and pathways. A promising role for cannabinoids in comparative study in 11 humans, Ali et al16 several eczematous dermatoses and pruritus investigated the use of 3% cannabis seed extract exists,24 and dermatologists are already implement- cream applied topically for the use of acne and ing cannabinoid therapy into their practices. For seborrheic dermatitis. Treated patients had lower pruritic patients without rash and with normal levels of skin sebum and erythema. thyroid, liver, and kidney function, one of our authors Endocannabinoids, synthetic cannabinoids, and recommends the use of a PEA-containing cream. A phytocannabinoids have also been shown to have PEA-containing cream has also been investigated for antitumor effects on keratinocyte carcinoma and use in pruritic patients with atopic dermatitis25 and melanoma both in vitro and in vivo.15 In mice has anecdotally relieved pruritus in several patients in inoculated with epidermal tumor cells, local our clinic at the University of Colorado. Although administration of a mixed CB1/CB2 receptor agonist cannabinoids may have anti-inflammatory and and a specific CB2 receptor agonist prevented antitumor effects, further clinical research is needed growth and vascularization of malignant tumors.17 before they can be used for these purposes clinically. Similarly, anandamide promoted cell death in tumor- Table I includes a list of cannabinoids discussed igenic skin cells but not in normal keratinocytes. and their potential dermatologic uses, sorted by Elevated levels of cyclooxygenase-2 in cutaneous psychoactive inactivity versus activity. tumor cells may lead to increased anandamide The authors thank Dr Hunter Sams, Clinical metabolic products, which in turn promote tumor Assistant Professor of Dermatology at the University of 190 Mounessa et al JAM ACAD DERMATOL JULY 2017 Colorado School of Medicine and staff physician at oxazolone-induced atopic dermatitis model. Ann Dermatol. VAMC East Colorado Region, for his clinical input and 2016;28:22-29. expertise. 13. Wilkinson JD, Williamson EM. Cannabinoids inhibit human keratinocyte proliferation through a non-CB1/CB2 mechanism REFERENCES and have a potential therapeutic value in the treatment of 1. State Medical Marijuana Laws: National Conference of State psoriasis. J Dermatolog Sci. 2007;45:87-92. Legislatures, 2016. Available at: http://www.ncsl.org/research/ 14. Marquart S, Zerr P, Akhmetshina A, et al. Inactivation of the health/state-medical-marijuana-laws.aspx. Accessed March 23, cannabinoid receptor CB1 prevents leukocyte infiltration and 2017. experimental fibrosis. Arthritis Rheum. 2010;62:3467-3476. 2. Compton WM, Han B, Hughes A, Jones CM, Blanco C. Use of 15. Soliman E, Ladin DA, Van Dross R. Cannabinoids as
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