To the Editor: Cannabinoids are endogenous and exogenous chemicals with antipruritic, anti-inflammatory, and antinociceptive properties yet to be fully explored.1 Increases in access to cannabinoid-derived medical products parallel the interest of patients and dermatologists regarding potential therapeutic uses for a variety of skin conditions.2,3 Connecticut is the only state currently listing psoriasis and psoriatic arthritis as indications for medical cannabis, though 7 states include arthritis. However, the scientific literature validating the efficacy and safety of cannabinoids for common chronic inflammatory skin diseases, such as psoriasis, is sparse.
Due to the lack of literature, often, expert opinion and experience is relied upon for emerging areas in dermatology.4 To assess expert perceptions on and experience with medical cannabis, an institutional review board–approved survey was disseminated to the National Psoriasis Foundation Medical Advisory Board in December 2021, with a 72% response rate (24/33). Table I summarizes respondent demographics and results. Among dermatologists, 83.3% were uncertain if psoriasis was an indication for medical cannabis in the United States; similarly, 80% of rheumatologists surveyed were unsure about psoriatic arthritis. However, 83.3% of respondents supported medical cannabis use, though only 25.0% have educated patients on medical cannabis and 21.7% have recommended medical cannabis. This is likely because 79.2% reported they did not have sufficient knowledge to explain the risks and benefits of medical cannabis; only 16.7% of respondents had prior education on medical cannabis. Importantly, 100% of respondents expressed interested in learning about the potential uses of medical cannabis, very much in parallel with past studies which found an overwhelming majority of dermatologists surveyed also wanted more education on medical cannabis applications (91% to 93%).2,5
Table I.
Survey results summary of psoriatic experts regarding medical cannabis
| Question | Answer | # of Responses | % of Responses |
|---|---|---|---|
| What is your primary specialty? | Yes | 18/24 | 75 |
| No | 5/24 | 21 | |
| Other | 1/24 | 4 | |
| What is your gender | Male | 17/24 | 71 |
| Female | 6/24 | 25 | |
| Prefer not to answer | 1/24 | 4 | |
| What is your age? | 24-34 | 1/24 | 4 |
| 35-44 | 7/24 | 29 | |
| 45-54 | 4/24 | 17 | |
| 55-64 | 7/24 | 29 | |
| 65+ | 5/24 | 21 | |
| How many years have you been in practice? | 0-5 | 2/24 | 8 |
| 6-10 | 4/24 | 17 | |
| 11-15 | 3/24 | 13 | |
| 16-20 | 2/24 | 8 | |
| 21-25 | 4/24 | 17 | |
| 26-30 | 3/24 | 13 | |
| 31+ | 6/24 | 25 | |
| What setting do you practice in? | Private practice | 10/24 | 42 |
| Academic institution/Veterans Affairs | 14/24 | 58 | |
| Where is the setting of your practice? | Large metropolitan area | 21/24 | 88 |
| Small metropolitan area | 2/24 | 8 | |
| Suburban/rural | 1/24 | 4 | |
| What is the legality of cannabis in your state of residence? | Legalized recreational and medical cannabis | 12/24 | 50 |
| Legalized medical cannabis only | 10/24 | 42 | |
| No legalized cannabis | 1/24 | 4 | |
| Unsure | 1/24 | 4 | |
| What is your state of residence? | California | 5/24 | 21 |
| Colorado | 1/24 | 4 | |
| Florida | 1/24 | 4 | |
| Illinois | 1/24 | 4 | |
| Maryland | 3/24 | 13 | |
| Massachusetts | 1/24 | 4 | |
| North Carolina | 1/24 | 4 | |
| New York | 6/24 | 25 | |
| Pennsylvania | 1/24 | 4 | |
| Ohio | 1/24 | 4 | |
| Ontario, Canada | 1/24 | 4 | |
| Texas | 1/24 | 4 | |
| Utah | 1/24 | 4 | |
| Do you support medical cannabis use? | Yes | 20/24 | 83 |
| No | 0/24 | 0 | |
| Unsure | 4/24 | 17 | |
| In the past year, how many patients or parents of patients have asked you about medical cannabis use? | 0 | 3/24 | 13 |
| 1-3 | 3/24 | 13 | |
| 4-6 | 1/24 | 4 | |
| 7-9 | 4/24 | 17 | |
| 10+ | 13/24 | 54 | |
| What forms of medical cannabis have you recommended? | Smoking/vaping | 1/6 | 17 |
| Topical | 3/6 | 50 | |
| Edible | 2/6 | 33 | |
| Have you ever educated your patients on medical cannabis use? | Yes | 6/24 | 25 |
| No | 18/24 | 75 | |
| Do you feel as though you have sufficient knowledge to explain the risks and benefits of medical cannabis treatment if asked by a patient? | Yes | 5/24 | 21 |
| No | 19/24 | 79 | |
| Do you believe that medical cannabinoids can worsen psoriatic disease? | Yes | 1/24 | 4 |
| No | 13/24 | 54 | |
| Unsure | 10/24 | 42 | |
| Do you believe that medical cannabinoids can inhibit the TH17 pathway? | Yes | 4/24 | 17 |
| No | 3/24 | 13 | |
| Unsure | 17/24 | 71 | |
| If a cannabinoid-based drug was approved by the Food and Drug Administration, would you feel comfortable proposing it to your patients? | Yes | 17/24 | 71 |
| No | 0/24 | 0 | |
| Unsure | 7/24 | 29 | |
| Have you previously recommended medical cannabis to your patients? | Dermatologist: yes | 3/18 | 17 |
| Dermatologist: no | 15/18 | 83 | |
| Rheumatologist: yes | 2/5 | 40 | |
| Rheumatologist: no | 3/5 | 60 | |
| Can over-the-counter/recreational cannabis products have any therapeutic benefit?? | Dermatologist: yes | 5/18 | 28 |
| Dermatologist: no | 2/18 | 11 | |
| Dermatologist: unsure | 11/18 | 61 | |
| Rheumatologist: yes | 2/5 | 40 | |
| Rheumatologist: no | 0/5 | 0 | |
| Rheumatologist: unsure | 3/5 | 60 |
Summarized demographic data and survey responses.
Beyond familiarity, 55.5% and 60% of Medical Advisory Board dermatologists and rheumatologists, respectively, believe medical cannabis is safe for their patients, and no respondents believed that medical cannabis is unsafe. Reasons against recommending medical cannabis included limited knowledge (60.0%), no experience (45.0%), and discomfort (20%). While only 21.1% of respondents previously recommended medical cannabis, 33.3% stated they are likely to recommend medical cannabis in the future, and only 16.7% stated they are unlikely to do so, highlighting a large subset who are undecided, likely due to limited experience.
54.2% of respondents reported 10 or more patients asked about medical cannabis in the past year. This is a remarkable increase in comparison to a 2018 survey study revealing 9.1% of dermatologists surveyed encountered 10 or more patients who asked about medical cannabis in the past year.5 This comes as no surprise given the rise in both consumer acceptance and utilization was highlighted in a recent survey study finding that 88% (n = 508) of participants approve of medical cannabis use.2
These data highlight that while experts support the use of medical cannabis and are recommending cannabinoids to some degree, gaps in education and research, rather than safety, are limiting dermatologists’ and rheumatologists’ comfort with medical cannabis for psoriasis. Regardless, increasing interest and utilization of medical cannabis among patients stress the importance of dermatologists being prepared, which in turn requires both mechanistic and clinical evidence-based education and training.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
IRB approval status: This study was performed with approval from The George Washington University Institutional Review Board (IRB protocol #NCR191607).
Key words: atopic dermatitis, cannabis, cannabinoids, dermatology, education, general dermatology; inflammation; medical cannabis; psoriasis; psoriatic arthritis, risk.
References
- 1.Nickles M.A., Lio P.A. Cannabinoids in dermatology: hope or hype? Cannabis Cannabinoid Res. 2020;5(4):279–282. doi: 10.1089/can.2019.0097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Yeroushalmi S., Nelson K., Sparks A., Friedman A. Perceptions and recommendation behaviors of dermatologists for medical cannabis: a pilot survey. Complement Ther Med. 2020;55 doi: 10.1016/j.ctim.2020.102552. [DOI] [PubMed] [Google Scholar]
- 3.Yeroushalmi S., Nemirovsky D., Mamlouk M., et al. Consumer perspectives on and utilization of medical cannabis to treat dermatologic conditions. J Drugs Dermatol. 2022;21(1):31–36. doi: 10.36849/jdd.2022.6540. [DOI] [PubMed] [Google Scholar]
- 4.Boguniewicz M., Alexis A.F., Beck L.A., et al. Expert perspectives on management of moderate-to-severe atopic dermatitis: a multidisciplinary consensus addressing current and emerging therapies. J Allergy Clin Immunol Pract. 2017;5(6):1519–1531. doi: 10.1016/j.jaip.2017.08.005. [DOI] [PubMed] [Google Scholar]
- 5.Robinson E., Murphy E., Friedman A. Knowledge, attitudes, and perceptions of cannabinoids in the dermatology community. J Drugs Dermatol. 2018;17(12):1273–1278. [PubMed] [Google Scholar]