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Cannabinoids For Skin Diseases and Hair Regrowth - 2021
Cannabinoids For Skin Diseases and Hair Regrowth - 2021
DOI: 10.1111/jocd.14352
REVIEW ARTICLE
1
Division of Dermatology, Department of
Medicine, University of Toronto, Toronto, Abstract
Ontario, Canada
The use of cannabis for skin diseases and hair regrowth is at the preliminary stage.
2
Mediprobe Research Inc, London,
Ontario, Canada
Legalization: Many countries have approved cannabis for medical use; however, four
countries Canada, Uruguay, South Africa, and Georgia have legalized it for both medi-
Correspondence
Aditya K. Gupta, 645 Windermere Road,
cal and recreational purposes.
London, Ontario, N5X 2P1, Canada. The endocannabinoid system: The endocannabinoid system may maintain skin ho-
Email: agupta@mediproberesearch.com
meostasis; two notable endocannabinoids include 2-Arachidonoylglycerol (2-AG) and
N-arachidonoylethanolamine (AEA).
Routes of administration and pharmacokinetics: Topical cannabinoids can avoid the
first-pass metabolism and reduce respiratory side effects; however, the high hydro-
phobicity of cannabinoids may hinder percutaneous absorption.
Skin disorders and hair growth: Human clinical studies suggest that cannabinoids
may be used in eczema, acne, pruritus, and systemic sclerosis treatment. Cannabidiol
(CBD) may enhance hair growth via multiple mechanisms.
Safety: Topical cannabis may cause mild side effects such as pruritus, burning, er-
ythema, and stinging; they are relatively safer than inhalation and oral cannabis.
Cannabis use may be associated with allergic symptoms and reduced immune re-
sponse to live vaccination.
Cannabinoids in practice: Despite growing interest, dermatologists should be cau-
tious prescribing cannabinoids due to insufficient clinical data on both efficacy and
safety.
KEYWORDS
cannabidiol, cannabinoids, endocannabinoid system, hair growth, skin diseases
TA B L E 1 Representative examples of
Endocannabinoids Phytocannabinoids Synthetic cannabinoids
cannabinoids6
2-Arachidonoylglycerol Delta9-tetrahydrocannabinol JWH−133
(2-AG) (THC)
N-arachidonoylethanolamine Cannabidiol (CBD) WIN−55,212–2
(AEA)
Palmitoyl ethanolamide Cannabinol (CBN) (R)-methanandamide (MET)
(PEA)a
N-arachidonoyl dopamine Cannabigerol (CBG) CP 55,940
Virodhamine Cannabidiolicacid (CBDA)
a
PEA is not a true endocannabinoid. It does not directly bind the cannabinoid receptors—only
promotes the binding of other endocannabinoids.
legalization status, pharmacokinetics, routes of administration, and quality herb.7 In ancient India, cannabis was
as a harmless high-
current practice norms of cannabinoids, with a focus on skin dis- widely used in religious festivals and also for medicinal purposes as
eases and hair regrowth. an anesthetic, analgesic, anti-parasitic, and so forth.7 The Buddhist
monks of Tibet considered cannabis as a sacred plant and frequently
used it for meditation in “Tantric Buddhism.”7 Perhaps the first re-
2 | S E A RC H S TR ATEG Y A N D M E TH O D corded warning about cannabis came from Galen, a Greek physi-
cian in the Roman regime. He recommended not to consume excess
We performed a structured and comprehensive search on PubMed hemp seed cakes during dinner parties, which was a common prac-
and Google scholar. The principal search strategy focused on using tice at that time7; hemp is a Cannabis sativa plant variety.7 In 1984,
the advanced search builder feature of PubMed—various keywords Pope Innocent VIII declared cannabis sinful and prohibited its use.7
and MeSH terms were used for the skin endocannabinoid system The attitude toward cannabis may be changing. Cannabis is ap-
(ECS), pharmacokinetics, routes of administration, cannabinoids’ proved for medical use in many countries; however, only Canada,
use in skin disorders treatment, clinical trials, cannabinoids and hair Uruguay, South Africa, and Georgia have legalized it for both medi-
growth, risk of using cannabinoids, and its use in practice. A comple- cal and recreational purposes. In the USA, different states have ad-
mentary search using similar keywords was conducted on Google opted different cannabis policies.8 Table 29-11 compares the timeline
scholar. We also conducted further web-based searches on Google, of cannabis legalization in the USA and Canada.9-11 Europe is rela-
RxTx database, and RxFiles to find relevant “grey literature” (e.g., tively behind, with the legalization of cannabis for medical use in the
standard practice norms, non-journal publications, reports, web- Netherlands, Germany, and Italy.8
sites, etc.). Additionally, we hand-searched the bibliographies of se-
lected articles to identify grey literature sources. Figure 1 details the
search strategy and the exclusion criteria. 4 | TH E S K I N E N D O C A N N A B I N O I D
S YS TE M
USA Canada
1937 The Marihuana Tax Act imposed a high tax on cannabis 1923 Narcotics Drug Act Amendment Bill made
cannabis illegal
1793 Oregon, the first state that lessened the penalty for possessing 2001 Health Canada launched medical
cannabis marijuana program
1996 California legalized the medical use of cannabis 2015 A task force was formed for the
legalization of cannabis possession
2012 Colorado and Washington legalized the recreational use of cannabis 2018 The Cannabis Act legalized the
recreational use of cannabis
April 2021 17 states, 2 territories, and the District of Columbia legalized
recreational use of cannabis
May 2021 36 states and 4 territories legalized the medical use of cannabis
F I G U R E 2 The endocannabinoid
system (ECS) in skin.12,13 2-AG,
2-Arachidonoylglycerol; AEA, N-
arachidonoylethanolamine; CB1,
Cannabinoid receptor type 1; CB2,
Cannabinoid receptor type 2; GPR55,
G protein-coupled receptor 55; PPAR-γ,
Peroxisome proliferator-activated
receptor-γ; TRPV, Transient receptor
potential cation channels (vanilloid)
5 | RO U TE S O F A D M I N I S TR ATI O N A N D
PH A R M ACO K I N E TI C S
TA B L E 3 Pharmacokinetics of cannabinoids3,23,24
pharmacokinetic properties of cannabinoids, especially absorption, respiratory symptoms such as pulmonary function reduction, bron-
3,23,24
vary depending on the route of administration (Table 3). chitis, coughing, and wheezing. 22 “Canna-
vaping,” on the other
hand, is an emerging alternative to smoking 22—where an electronic
device heats cannabis to produce vapor of water and cannabinoids
5.1 | Topical for inhalation. 22 The vapor contains less carbon monoxide and toxic
substances than the smoke, suggesting it might cause relatively less
The topical application of cannabinoids for skin diseases may be ad- respiratory distress and other relevant side effects. 22
vantageous because of the ability to act locally at the disease site.
Topical cannabinoids also have two added advantages compared
to inhalation and oral routes. First, it is expected to cause fewer 6 | H U M A N C LI N I C A L S T U D I E S
respiratory side effects than inhalation dosing. Second, unlike oral
cannabinoids, it can avoid the first-pass metabolism. 25 Arguably, the This section discusses eight human clinical studies that investigated
substance abuse potential is lower with cannabinoid transdermal cannabinoids’ use in various skin disorders treatment. The articles
25
patches because it releases the drug slowly from the reservoir. were selected based on the inclusion and exclusion criteria described
However, the hydrophobic nature of cannabinoids may hinder per- in the search strategy and method section. Table 414-21 briefly sum-
23
cutaneous absorption, leading to reduced therapeutic effect. marizes the studies.
Oral cannabinoids, especially “edible cannabinoids” (cannabis- A randomized, single-blinded crossover study was conducted on a
infused foods and beverages), are gradually becoming popular among small sample size of 20 atopic dermatitis patients, who were catego-
users. 22 However, its potency and bioavailability are unpredictable— rized into two groups—the experimental group took 30 ml hempseed
the onset is often delayed, which may provoke the user to consume oil daily by mouth, and the control group took olive oil at the same
more, eventually leading to overdose and intoxication. 22 dose, route, and frequency. 20 Hempseed oil significantly improved
serum fatty acid profiles and atopic dermatitis symptoms such as
skin dryness and itchiness. 20 The improvement could be attributed
5.3 | Inhalation to omega-
6 and omega-
3 polyunsaturated fatty acids found in
hempseed oil. 20 No severe side effect was observed; however, only
Cannabis can be inhaled either by smoking or by “canna-vaping.”22 one patient discontinued due to the poor taste of hempseed oil. 20
22
Smoking is probably the most popular route in North American —a Palmitoylethanolamide (PEA), an endogenous fatty acid and
recent US survey found that more than 90% of adult users pre- regulator of the ECS in the skin, may bind to the CB2 receptor
ferred smoking. 22 However, cannabis smoking is associated with on mast cells, stabilize them, and result in downregulation of T
GUPTA and TALUKDER
Eczema Callway et al. Hempseed oil Improved skin dryness and itchiness No side effect, but one patient discontinued due
Improved serum fatty acid profiles to hempseed oil's poor taste
Del Rosso PEA-containing nonsteroidal cream plus topical Rapid remedy of initial disease flare Mild, transient stinging
mid-potency corticosteroids Delayed the next disease flare by
approximately 28 days
Eberlein et al. PEA-containing cream Improved disease symptoms Minor side effects such as pruritus, burning,
Improved sleep quality erythema, etc. in 1% of the total study
population
Reduced use of topical corticosteroids
Yuan et al. PEA-/AEA-(0.3%/0.21%) containing cream Improved disease symptoms No side effect observed
Improved skin hydration
Acne Ali et al. 3% cannabis seed extract cream Significantly reduced sebum and erythema No side effect reported
content
Pruritus Szepietowski et al. PEA-and AEA-containing cream Completely reduced pruritus in 38% of the No side effect reported
patients
Completely reduced xerosis in 81% of the
patients
Visse et al. PEA-containing lotion No significant difference between vehicle Minor side effects such as pruritus, stinging,
and the lotion scaling, or reddening
Systemic sclerosis Spiera et al. Oral Lenabasum CRISS score significantly improved No severe drug-related side effect
Minor side effects such as dizziness, fatigue,
headache, arthralgia, upper respiratory tract
infection, nausea, and decreased forced vital
capacity
Abbreviations: AEA, N-acetylethanolamine; CRISS score, combined response index in diffuse cutaneous systemic sclerosis score; PEA, N-palmitoylethanolamine.
|
2707
|
2708 GUPTA and TALUKDER
helper cell type 2-m ediated response in atopic dermatitis.16 An 6.4 | Systemic sclerosis
investigator-b linded, randomized, split-b ody clinical study, con-
ducted on 43 patients (18 adults and 25 children), compared (i) Lenabasum, a synthetic CB2 receptor agonist, when used in sys-
PEA-containing cream plus topical mid-p otency corticosteroids temic sclerosis significantly improved the CRISS score (Combined
versus (ii) moisturizer cream plus the same corticosteroids for Response Index in diffuse cutaneous Systemic Sclerosis) com-
16
six weeks. Each patient applied two creams on two sides of the pared to the placebo in a phase II, randomized, double-b linded
body.16 The use of PEA rapidly cleared the initial disease flare and study (Lenabasum CRISS score: 0.33 vs. placebo CRISS score:
also delayed the next flare by approximately 28 days; however, the 0.00). 21 Twenty-s even of 42 patients took oral Lenabasum, and 15
statistical significance of the outcomes was not mentioned in the patients took placebo. 21 The doses of Lenabasum were 5 mg once
article.16 Two of 25 children experienced a mild, transient stinging a day, 20 mg once a day, or 20 mg twice a day for the first four
using PEA-containing cream.16 weeks, then 20 mg once a day for eight weeks. 21 Approximately
Eberlein and his group conducted a prospective and obser- 63% of the Lenabasum group versus 60% of the placebo group
vational study on 2456 atopic eczema patients where they ap- reported side effects such as dizziness, fatigue, headache, ar-
plied PEA-containing cream at least twice a day for four to six thralgia, upper respiratory tract infection, nausea, and decreased
weeks.17 The PEA cream reduced disease parameters such as dry- forced vital capacity, but no severe drug-related side effects were
ness, scaling, erythema, pruritus, excoriation, and lichenification observed. 21
17
in 58.6% of the patients. Patients also reported significant re-
duction in pruritus and improvement of sleep quality.17 Moreover,
study subjects were able to reduce topical steroid application.17 7 | C B D A N D H A I R R EG ROW TH
Side effects (1% subjects) were minor and included pruritus,
burning, and erythema.17 The study lacked a control group and Being a negative allosteric modulator to the CB1 receptor, CBD may
randomization. promote hair growth because the stimulated CB1 receptor hinders
A double-blinded, randomized trial (N = 60 patients) showed the hair shaft elongation, reduces keratinocyte proliferation, and in-
that PEA-/AEA (0.3%/0.21%)-containing cream applied twice duces premature hair follicle regression (Figure 4). 26,27 It may also
daily for 28 days significantly (p < 0.05) improved asteatotic ec- help in maintaining the anagen phase by differentiating dermal pro-
zema symptoms (skin scaling and itching) compared to the control genitor cells into new hair follicles through the Wnt/β-catenin path-
cream.19 More importantly, the skin hydration was considerably bet- way. 27,28 Figure 426-29 illustrates the proposed mechanisms of CBD
19
ter in the PEA-/AEA-cream group. in hair regrowth.
CBD is also a TRPV1 (Vanilloid receptor-1) and TRPV4 (Vanilloid
receptor-4) agonist. 27 The activation of TRPV1 negatively impacts
6.2 | Acne hair growth, but excessive activation desensitizes the recep-
tor and may indirectly help growing hairs (Figure 4). 27 An ex vivo
14
Excessive sebum production is associated with acne development. study found that the high concentration of CBD (10 µM) activated
In a single-
blinded, randomized trial, 3% cannabis seed extract TRPV4 receptors and significantly reduced hair shaft development
cream significantly reduced the sebum production compared to the and induced apoptosis. However, at a low concentration (0.1 µM),
base cream (control).14 Each of 11 patients who participated in the it increased hair shaft elongation perhaps via adenosine receptor
trial applied the cannabis cream on one side of the face and the base (Figure 4). 29
cream on the other side for three months.14 The authors did not re- A recent study conducted on 35 AGA patients (28 males, 7 fe-
port any side effects. males) showed that once-daily application of CBD-rich hemp oil
for six months (3–4 gm/day) increased the non-vellus hair count by
93.5%. Males experienced slightly better outcomes than females;
6.3 | Pruritus neither group reported any significant side effects. 27
F I G U R E 4 Proposed mechanisms of CBD in hair regrowth. 26-29 β-cat: Beta-catenin; CBD: Cannabidiol; CB1: Cannabinoid receptor type 1;
TRPV1: Transient receptor potential cation channel subfamily V member 1; TRPV4: Transient receptor potential cation channel subfamily V
member 4
may not be associated with severe harm.30 However, buying topi- 8.2 | Cannabis allergy
cal cannabis products from non-regulated or illegal sources may be
concerning due to the unknown pesticide exposure, impurities, or Cannabis allergy incidences are thought to be under-reported.5 The
30
unspecified potency. It may significantly increase the risk of infec- allergy response may be administration route-dependent. For exam-
30
tion if applied to the compromised skin. Patients should be extra ple, a patient who ingested hempseed developed an anaphylactic
careful using THC-containing topical products on skin wounds or reaction, but the same patient did not show any allergic symptoms
cracks since it might increase the systemic absorption and cause side with cannabis smoking.5 Several other studies also reported aller-
30
effects such as euphoria. gic responses to cannabis, hempseed, or both. Cannabis also shows
|
2710 GUPTA and TALUKDER
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