Cannabis-Related Product Use Among Patients with Hidradenitis Suppurativa: Insights from Adam Friedman, MD

New research offers new insights on the use of cannabis among patients with hidradenitis suppurativa. The findings don't surprise Adam Friedman, MD, Professor and Chair of Dermatology and Director of the HS program at GW School of Medicine and Health Sciences. He shares his insights on the paper, published in the Journal of Cutaneous Medicine and Surgery, and offers tips for counseling and managing patients. Dr. Friedman is a Director of the American Acne and Rosacea Society. 

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Transcript

This transcript is provided as a courtesy. It has not been edited for transcription errors.

This is Hot Topics, from the American Acne and Rosacea Society. Thank you for joining us as we take a closer look at the recent publication Evaluation of Cannabis-Related Product Use Among Patients with Hidradenitis Suppurativa, a narrative review. We are joined by AARS Director Dr. Adam Friedman. Dr. Friedman is professor and chair of dermatology and director of the HS Program at GW School of Medicine and Health Sciences. He shares his insights on the paper, which was published in the Journal of Cutaneous Medicine and Surgery, and addresses the potential future for cannabis-related care in dermatology.

Dr. Adam Friedman:

So Hidradenitis Suppurativa, or HS, is a huge pain in the fill-in-the-blank and I mean this in many different respects from the disabling and recurrent and chronic nature of this inflammatory disease to the point that it is extraordinarily painful and I think this is often missed and something we need to ask our patients and also address. Because there aren't great guidelines and evidence-based practices when it comes to pain management in the world of dermatology as it relates to HS, a lot of patients are known to self-medicate and there are several studies evaluating the rise of utilizing both illegal and accessible pain regulatory medications.

The paper here looks to what's out there in the literature with respect to A, our individual with HS using cannabis as a mechanism to address pain and maybe other symptoms. What is that frequency and what is the rationale behind that? Now when we think about cannabinoids, plant-derived when we think about cannabis, synthetic made in the lab, or even our own endocannabinoids, which are arachidonic acid derivatives that you and I and everyone you know are making on a minute-by-minute basis to control a whole host of biological mechanisms and functionalities, we have to think about how do they work in the living system.

And yes, no question. We could think about how certain cannabis-derived ingredients could work on pain, itch, overall mentation, but there's a lot more going on beneath the surface when it comes to the translatability of these bioactive molecules. And so here in this really well-thought-out review where investigators whittle down studies that were looking at the utilization of specifically cannabis in the world of HS and I believe they got it down to about six or seven studies encompassing over 30,000 patients. They found that one, individual with Hidradenitis Suppurativa are using cannabis at a much higher rate as compared to maybe other conditions or even maybe the general public, but two, that they were using it for different reasons, controlling pain, helping with sleep, mentation, getting over the fact that this condition can be extraordinarily destructive and disabling if not medically controlled. And what I really liked about the paper is that it wasn't a, "Hey. Here's what's going on. Here's why it's being done."

And cliff, nothing after. The investigators actually offered approaches for both patients and healthcare practitioners to think critically about how to assess for the utilization of cannabis. We know that medical cannabis or even recreational use of cannabis is legal in a good number of states in the United States, let alone in Canada. Across Canada it has been legalized and actually there are fewer states where medical cannabis is illegal versus legal or decriminalized. So access is out there. What I really love about this paper is that it offered guidance about how to talk to patients about it, how to think about it, not so much about dosing, which I think we still have a lot to really work on, but at least it gives a framework to have a real conversation and really partner with our HS patients to ensure that they are really being purposeful with their cannabis use, not overdoing it. Really less is more when it comes to this, but also provides a way for us to document and monitor these patients over time as well.

Speaker 1:

When it comes to cannabis use in HS, the perceived benefit may go beyond pain control Dr. Friedman says.

Dr. Adam Friedman:

So I found in my own practice, and I'm sure many of you have witnessed this as well, that HS patients are very frustrated with the limited armamentarium we have available to medically and even surgically manage their disease, but especially when it comes to pain, it's even more of a nebulous, murky area where I think a lot of dermatologists don't feel comfortable discussing pain management or even thinking about schedule two or three drugs or opioids or things like that to really control that pain. And no question, patients will find one way to control their pain one way or another. So we know that HS patients are seeking out various forms of cannabis, whether it be topical, oral, inhalational to control whether it be pain, itch, or even just manage the disease in general. And I guess the first question you have to ask is is there a rationale behind this and is this a more appropriate route to manage let's say pain over using more traditional pain and management routes?

And my belief is the answer is yes to all the above. When we think about some of the more and better studied cannabinoids like THC or CBD, both have potential to manage symptomatology, but they also have, and what I think this paper didn't really dive too much into, very potent anti-inflammatory or maybe better said, pro-inflammation resolution properties. Those are two very different things. When we think about anti-inflammatories, we're thinking about inhibiting inflammatory pathways, especially nowadays with precision medicine with biologics. It's blocking a receptor, blocking a signal. Cannabinoids specifically can work through what's called the resolvent pathway, a unique pathway that signals to the immune response to shut down. You don't have to go home, but you can't stay here, but also can polarize certain immune cells to more rebuild profiles or phenotypes rather than destructive like macrophages for example.

And that's very unique. I think it's not just about blocking or inhibiting, but rather facilitating a resolution of the inflammatory milieu which cannabinoids can uniquely participate in. So I think that yes, at very basic superficial level, cannabinoids through their activity on a nerve specifically. So we know that our endocannabinoids can shut down nerve transmissions through the activation of calcium receptors and kind of negative feedback to the presynaptic cleft and we know that THC for example can do the same thing. But we also know that cannabinoids can work through various vanilloid receptor pathways and many more beyond that. And so yes, I think there's a role for controlling symptoms, but I'm even more excited in exploring the role of cannabinoids for their impact on inflammation.

And we're seeing the emergence of various cannabinoids being used for that, whether it be atopic dermatitis, acne vulgaris, even protecting against DNA damage from ultraviolet radiation exposure like we showed in a clinical trial recently published in the Journal of American Academy of Dermatology. So I think HS is the next cannabinoid frontier because I think it covers the gamut of both symptoms, but also underpinnings of disease. And this really nice review highlights that, it reminds us that, but also it starts to kick us in the behind to start talking to our patients about it, giving us a framework to do so. Newsflash ladies and gentlemen, your Hidradenitis Suppurativa patients are pursuing unique ways to control their pain and other symptoms.

And several papers have highlighted that one of those ways is using cannabis-based products. Now this should come as no surprise given the rapid increase in accessibility through the legalization of both recreational but even medical marijuana throughout the United States, let alone outside in Canada for example, super accessible. Now you may not feel comfortable talking to patients about it. Actually we have shown, we have published, that dermatologists, residents, pediatric dermatologists don't necessarily feel armed with the right information to do so. In a recent publication entitled Evaluation of Cannabis-Related Products Use Among Patients with Hidradenitis Suppurativa, a narrative review published in the Journal of Cutaneous Medicine and Surgery, author has not only highlighted the prevalence and use of cannabis-based products in the HS population, why they're using it, but they also provided a basic framework of how to talk to patients about it.

Also, they gave us a framework for how the patients approach us about it. So while there's a lot more questions than answer when it comes to what is the best formulation, what is the best dosing, what about combination of cannabinoids, whether it be plant-derived or synthetic, we at least have a basic framework and a starting place of how to address it with patients, what you should be documenting in your note so that you maintain the mantra of go low and slow and how they can then of course approach you when they have more questions or concerns related to the use of cannabis within the framework of their therapeutic approach. So we got a lot more work to do here. I strongly believe that cannabinoids could be an incredible addition, both from a controlling inflammation but also symptom perspective, but that's where more research is needed to assure that when we make this recommendation, that it is generalizable to all of our HS patients.

Speaker 1:

So what is the future for cannabinoids in dermatology?

Dr. Adam Friedman:

I think the cannabinoid space is ripe for the picking in dermatology. We are absolutely behind in this game due to the controversy, the illegal nature, the Schedule 1 C classification of any ingredient from the cannabis plant that has stymied research and development for so long. Since the unearthing or maybe the unchaining of this entire industry, we have seen a rapid evolution of science, but also the emergence of many, and unfortunately so, products in the marketplace that are really banking on the allure, not having the science, not having evidence to really support claims. And so I think we saw a second hit to the credibility of this space.

However, when you sift away and wash away all the gunk, all the dirt, from unfortunate misdirection and of course limitations to accessing these ingredients to study and develop, I think there is so much promise here. And the reason for this is, at the end of the day, using, whether it be plant-derived endogenous or synthetic cannabinoids, they are capitalizing on a very important biological system, which we are all using right in this moment, our endocannabinoid system. And so it's understanding how these ingredients work in the biological system and marrying that with our understanding of pathophysiology, which we have really done a great job of explaining and characterizing, whether it be psoriasis, atopic dermatitis, Hidradenitis Suppurativa, lichen planus, and many more.

And so I think that, because of the ubiquitous activity of these cannabinoids in the living system, how it's not a one-hit wonder, it's not going after one signal, one receptor, but rather orchestrating a wide variety of biological activities, I think there's even more opportunity for cannabinoids than a lot of our current amazing therapeutic options. But what is needed? Investment, research, time, passion, energy, an army of medical students who are willing to put the time in with the hope of getting that coveted residency spot, all the above. We need more efforts, but even with the limited clinical data, because really at the end of the day, it's clinical data, the limited clinical data, looking at whether it be a CBD gel for atopic dermatitis, whether it be a nanoencapsulated CBD formulation to protect against the expected DNA damage from UVA radiation.

There are already very bright signals that there is a very bright future for cannabinoids. It's just we're going to require the legwork and I hope that all the noise around it does not distract from the clear and evident promise that cannabinoids have for us and our patients.

Speaker 1:

Thank you for joining us for this edition of Hot Topics from the American Acne and Rosacea Society. And special thanks to our guest, Dr. Adam Friedman. For more updates on research in acne, rosacea, and HS, check out the semi-monthly Hot Topics newsletter. The Hot Topics Newsletter is an AARS member benefit delivered to your email inbox. Get more information online at acneandrosacea.org.