Why I Love Cannabis Topicals: Clinical Pearls for Topical Cannabis Use
JAKE F. FELICE, ND, LMP
The purpose of this article is to describe one clinician’s experience with medical cannabis.
Why Cannabis Topicals?
Non-steroidal anti-inflammatory drugs (NSAIDS) and opiates represent the mainstay of pharmacological treatment for pain. Their use is increasing over time1–3 and they are associated with very significant morbidity and mortality.4–7 Viable alternatives to opiates and NSAIDS are desperately needed. Medical cannabis possesses very low toxicity, can be used along with opiates, is effective for pain, is generally well tolerated, and is associated with significant decreases in the use of both NSAIDS and opiates.8–11
Cannabis topicals are an ideal introduction to the world of medical cannabis for cannabis-naïve patients. One reason is that topical products, even the ones containing tetrahydrocannabinol (THC), do not give patients a head high. Also, because cannabis topicals bypass the digestive system, they avoid first-pass metabolism in the liver and therefore pose no risk for potential herb-drug interactions.
Topical cannabis products include infused oils, lotions, and balms that can be applied to the skin. They are an affordable and increasingly accessible modality for pain relief, itch, and inflammation. New transdermal innovations, including transdermal patches, are fast arriving in the cannabis and cannabidiol (CBD) markets. Consumers throughout all 50 states now have access to hemp-derived cannabis topical products via online purchasing.
This paper focuses on clinical pearls and applications that this plant has taught me over the last 15 years. For those readers who are interested in a more in-depth look at the research than is covered in this paper, please see my online article “Topical Cannabis: Research Review.”10
The skin is the largest organ of the body, yet its importance is often neglected by clinicians. It acts as a barrier and is our first line of defense. Skin is responsible for critical transmission of biologic information, exchanging and receiving data from events in the external environment, and transmitting them to our internal organs and immune system. This biologic information travels via neural, endocrine, and immune cell messaging, as well as via the endocannabinoid system (ECS) to regulate local and global homeostasis.12
A large percentage of my patients use topical cannabis products combined with oral cannabis products, and report positive results when combining these delivery methods. This makes sense given the synergistic coordination between peripheral, spinal, and central sites of the ECS in the central nervous system.13–19 Additionally, it is likely that additive or synergistic effects are occurring not only between different cannabinoids, such as THC and CBD, but also between topical cannabinoids and topical opiates.18
Applications & Clinical Pearls
Topical cannabinoids may significantly improve skin barrier function,20 which is an essential feature in addressing itch.21 Certain phytocannabinoids that enhance sebum production may be effective in treating dry-skin syndrome.22 Evidence from cell-culture, human, and animal studies also demonstrates potential applications for topical cannabinoids in the following areas:
- Wound healing25-27
- Multiple sclerosis36
- Contact dermatitis37-39
- Atopic dermatitis37
- Neuropathic pain40-42
- Post-operative pain17
Additional properties of topical cannabinoids derived from in-vitro and animal studies include inhibitory effects on sebocyte proliferation23 and differentiation, tumorigenesis, inflammation, sensation of pain, and itch.12,21
Topical cannabis products are dose-dependent, meaning that a critical amount (concentration) of cannabinoids contained in topical preparations is essential for achieving optimal relief.10 Also, the more cannabinoids one applies to the skin, the more effective they are. Cannabinoid concentration is an important consideration when making product recommendations to patients; ie, they should be informed of this concentration-dependent attribute when they are shopping online for the most effective products.
It is also important to explain to patients that topical cannabis products are not miracle drugs. They should be informed that cannabis topicals are mildly effective for pain and are typically short-acting, providing relief that typically lasts between 4 and 5 hours. Frequently, multiple applications may be necessary for maximum relief.
Patients can be reassured that, according to the limited available human research, topical cannabis products are generally well tolerated.43,44 Because absorption of topicals can be enhanced by carrier ingredients such as ethanol,45,46 attention to the carriers with which a topical cannabis product is delivered is important in order to ensure efficient transmission across the skin barrier.
One easy way to enhance absorption of cannabinoids across the skin barrier is to use an alcohol-based tincture of cannabis as a spray. In addition, applying copaiba oil or castor oil to the skin after using the cannabis spray may help drive the cannabinoids through the epidermis. These oils have been shown in animal models to penetrate well and possess anti-inflammatory and pain-relieving properties in their own rights.47,48 An anti-inflammatory oil can offer potential additive and synergistic effects when given along with cannabinoids. “Driving” agents such as dimethyl sulfoxide (DMSO) may also be considered.49 DMSO also has anti-inflammatory properties,46 though it may not be as well tolerated as a cannabis topical.
Shock wave therapy or ultrasound can also enhance absorption of topical cannabis by helping drive the topical through the epidermis immediately following its application.50,51 This might be a consideration for clinicians who already have this equipment in their offices.
CBD in Sunscreens
Research indicates that the ECS plays a role in the detection of tissue injury.52 Interestingly, the ECS is also involved in protecting skin from ultraviolet (UV) radiation.53,54 Specifically, topical cannabinoids may offer protection after UV sun exposure.55 A recent study described dose-dependent protective effects of CBD on UV-exposed melanocytes and keratinocytes.56 Because CBD does not exhibit absorption in the UVB spectra, this effect was thought to be due to the scavenging of reactive oxygen species (ROS) rather than the blocking of UV exposure.56
Topical CB2 Agonism
Beta-caryophyllene in Topicals
Stimulation of cannabinoid receptor-2 (CB2) has been shown in mice to reduce neuropathic pain.57 Beta-caryophyllene is a terpenoid in cannabis that acts as a CB2 receptor agonist and has been demonstrated to specifically diminish neuropathic pain in animals.58 Beta-caryophyllene has also been shown to contribute to the entourage effects of cannabis.59 I have personally found products rich in beta-caryophyllene to be advantageous for pain, especially when there is an element of neuropathic pain involved.
Although I am unaware of any peer-reviewed research specifically examining the effects of topical cannabis products containing high levels of beta-caryophyllene, the animal research gives us reason to consider these in topical formulations. This is an area that will benefit from future research.
The high concentration of beta-caryophyllene in oils such as copaiba oil60 makes them ideal as carrier oils for topical cannabis products. Black pepper and rosemary also contain large amounts of beta-caryophyllene, thus can be added as support herbs to a topical botanical formula containing hemp or cannabis.59 Many cannabis products come with certificates of analysis (COAs), and patients can be instructed in how to search for and read COAs online at the manufacturers’ websites.
Another botanical compound that stimulates the CB2 receptor is Echinacea. Its alkylamide molecules bind to the CB2 receptor, even at low nanomolar concentrations.61
Multiple naturopathic physicians have found that Echinacea can positively impact neuropathic pain in shingles. Incorporating Echinacea into a tincture with cannabis may therefore be helpful as a topical when treating this condition. The vesicles that occur during shingles do not react well to lotions or creams due to their fragility, and the fragile, sensitive skin barrier can be disrupted by the pressure required to apply these products. A topical spray can be applied to the area so that the patient does not have to touch the skin directly.
I have also had numerous patients report moderate relief from flank pain during the passage of kidney stones after applying topical cannabis to the skin overlying the site of the pain.
Because topical cannabis products are generally well tolerated and do not cause a head high, these products can be an ideal choice for introducing patients to the therapeutic benefits of cannabis. Topicals are affordable, easy to apply, well tolerated, and do not adversely interact with systemic pharmaceutical drugs. While it is apparent that much more human research is needed to fully assess the potential benefits and limitations of the topical application of cannabinoids, their low toxicity along with high potential for benefit provides a good rationale for clinicians to consider topical cannabis lotions, creams, salves and patches in their treatment regimens.
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- Phillips JK, Ford MA, Bonnie RJ, eds. Trends in Opioid Use, Harms, and Treatment. In: Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington DC: National Academies Press; 2017. Available at: https://www.ncbi.nlm.nih.gov/books/NBK458661/. Accessed March 28, 2021.
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Jake F. Felice, ND, LMP is a cannabis author, clinician, educator, and consultant whose vision is to advance the science and practical application of cannabis for medical and recreational markets around the world. Dr Felice provides world-class educational experiences by speaking authentically about hemp and cannabis. He consults with healthcare providers, industry, and the general public. His Category 1 CME courses for doctors, nurses, and pharmacists has been translated into 4 languages. Dr Felice is the founder of Cannabis Matrix Consulting, LLC, and he maintains a regular cannabis blog at drjakefelice.com.