Cannabis arteritis: Getting higher on the differential diagnosis list of ulcerative lesions

By Warren R. Heymann, MD, FAAD, January 1, 2026

Vol. 8, No. 1

According to Shrivastava et al., “Cannabis is a complex plant with over 100 identified cannabinoids, such as delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), each with distinct physiological effects. THC is responsible for marijuana’s psychoactive properties. CBD is used for its non-psychoactive, therapeutic potential. Recent advances in research have unveiled a diverse range of interactions between cannabinoids and the skin. Cannabinoid receptors, notably cannabinoid receptor 1 (CB1) and cannabinoid receptor 2 (CB2), part of the endocannabinoid system, are distributed throughout the skin’s various cell types, including keratinocytes, sebocytes, and immune cells, and are the site where cannabis acts.” Adverse dermatologic complications of marijuana use include allergic contact dermatitis, urticaria, Stevens-Johnson syndrome, and cannabis-induced arteritis (aka cannabis arteritis (CA)). (3) Dermatologic complications may be secondary to other complications of cannabis use, such as abdominal erythema ab igne as reported by Green and Green in a woman using a heating pad to reduce the pain from her cannabinoid hyperemesis syndrome. (Dr. Green told me that he refers to this finding as “pot belly.”) (4) This commentary focuses on CA.

Although fewer than 100 cases of CA have been reported since first being described in 1960, (5) it may be underrecognized. CA predominantly affects young male cannabis smokers without other cardiovascular risk factors. (6, 7) Vaping high-potency THC may cause CA. (8) Clinically, claudication, Raynaud phenomenon, and superficial vein thrombosis may all precede digital ulceration. (6, 9) Digital ischemia may distort the nail bed, resulting in secondary nail changes such as leukonychia, splinter hemorrhages, Beau lines, onycholysis, and onychogryphosis. (6)

Most authorities consider CA a variant of thromboangiitis obliterans (TAO, Buerger disease), which is associated with tobacco products in young adults. It may be difficult to distinguish between the two, as many patients use tobacco and THC; however, CA may occur without concomitant use of tobacco. (10) Biopsies of involved arteries may demonstrate either thrombosis without inflammation or mild inflammation of the vessel media with fragmentation of the internal elastic lamina. (5) Angiography usually displays segmental occlusive lesions of the small and medium-sized vessels with corkscrew collaterals. (6)

Regarding the pathophysiology of CA, Kaniecki et al. state, “It has been proposed that the underlying mechanism of CA is related to THC, the primary active substance in cannabis, which has been found in animal models to cause excessive vasoconstriction through inhibited nitric oxide synthase and tyramine-like effects on adrenergic nerve endings. The lack of any inflammatory infiltrates on biopsy is supportive of the hypothesis that CA may be more of a secondary thrombotic process in the setting of arterial vasospasm as opposed to a primarily inflammatory pathology, but further research is needed to determine whether CA can be truly delineated from TAO mechanistically.” (5)

Therapeutically, the most critical maneuver is discontinuing cannabis consumption immediately and definitively. In the acute phase, anticoagulants, vasodilators (such as iloprost), platelet aggregation inhibitors (aspirin), hyperbaric oxygen, and revascularization may be required. Unfortunately, CA may necessitate amputation. (11, 12)

Point to Remember: Cannabis arteritis should be high on your differential diagnosis in young patients presenting with digital ulcerations. Immediate cessation of marijuana is mandatory to avoid the risk of amputation.

Our expert’s viewpoint

Viktoryia Kazlouskaya, MD, PhD, FAAD
Dermatologist and CEO
Vice Chair of Education
Dermatology Circle PLLC, NY

Cannabis arteritis (CA) is a rare peripheral vascular disease associated with chronic cannabis smoking. Fewer than 100 cases have been documented in the medical literature. Most reported patients are men under 45 years of age with no known cardiovascular risk factors. Only a few cases in women have been described. (13)

The exact pathogenesis remains unclear. Many patients simultaneously smoke tobacco, raising the possibility that CA may be a variant of Buerger’s disease. However, some individuals report exclusive cannabis use. The primary psychoactive component of cannabis, delta-9-tetrahydrocannabinol (THC), has been shown to exert vasoconstrictive effect that may play a role in the disease symptoms. (14)

Patients with CA typically present with limb pain and may experience claudication. As the condition progresses, necrotic lesions and/or gangrene can develop, most often affecting peripheral areas such as the toes, fingers, or ears. On physical examination, pulses in the affected limb are often diminished or absent. Diagnostic imaging, including Doppler ultrasound and angiography, usually reveals arterial obstruction.

Treatment involves immediate cessation of cannabis use, along with aggressive medical therapy, including anticoagulants, vasodilators (such as aspirin, pentoxifylline, or heparin), and, in some cases, hyperbaric oxygen therapy. In severe cases, surgical interventions, including arterial bypass or amputation, may be necessary.

With the growing use of recreational cannabis, clinicians should remain aware for this under-recognized condition. Moreover, cannabis use has been linked to other cardiovascular risks, including myocardial infarction and stroke. (15) Many questions remain unanswered. It is still unclear whether cannabis arteritis is a distinct entity or a variant of Buerger’s disease. Do other forms of marijuana (edibles, creams, oils, etc.) pose similar vasoconstrictor risks? I guess more research is needed.

References

1. https://nida.nih.gov/about-nida/noras-blog/2025/01/new-roadmap-cannabis-cannabis-policy-research (accessed June 6, 2025)

2. https://usafacts.org/articles/how-marijuana-laws-are-different-between-states (accessed June 6, 2025)

3. Shrivastava S, Shrivastava S, Shrestha M, Mahaju S. Cannabis and Dermatological Implications: A Traditional Review of Adverse Cutaneous Reactions and Systemic Risks. Cureus. 2025 Apr 21;17(4):e82711. doi: 10.7759/cureus.82711. PMID: 40400880; PMCID: PMC12094274.

4. Green KE, Green JJ. Erythema Ab Igne Associated With Cannabinoid Hyperemesis Syndrome. Mayo Clin Proc. 2023 Jun;98(6):826-827. doi: 10.1016/j.mayocp.2022.12.017. PMID: 37270269.

5. Kaniecki T, Huso TH, Haque UJ. Cannabis arteritis revisited: a case report with distinct pathologic features and review of the literature. Rheumatology (Oxford). 2024 May 3;63(6):e190-e192. doi: 10.1093/rheumatology/kead683. PMID: 38109679.

6. Cheuque RPR, Romero IMV, González LA, Jiménez-Gallo D, Barrios ML. Nail changes in cannabis arteritis. Int J Dermatol. 2025 Jun;64(6):1108-1109. doi: 10.1111/ijd.17541. Epub 2024 Oct 23. PMID: 39443747.

7. Ye IB, Hines GL. Marijuana and Vascular Disease: A Review. Cardiol Rev. 2024 Jan 8. doi: 10.1097/CRD.0000000000000649. Epub ahead of print. PMID: 38189379.

8. Colling M, Souri Y, Reifsnyder T. Tetrahydrocannabinol vape-associated cannabis arteritis in a patient with minimal tobacco exposure. J Vasc Surg Cases Innov Tech. 2024 Nov 8;11(1):101673. doi: 10.1016/j.jvscit.2024.101673. PMID: 39691796; PMCID: PMC11650286.

9. McBane RD 2nd, Koster MJ. Cannabis Arteritis and Recurrent Phlebitis. Mayo Clin Proc. 2023 Dec;98(12):1831-1832. doi: 10.1016/j.mayocp.2023.06.013. PMID: 38043999.

10. Pilitsi E, Kennamer B, Trepanowski N, Gonzalez R, Trojanowski M, Phillips T, Lam CS. Cannabis arteritis presenting with Raynaud's and digital ulcerations: a case-based review of a controversial thromboangiitis obliterans-like condition. Clin Rheumatol. 2023 Jul;42(7):1981-1985. doi: 10.1007/s10067-023-06603-x. Epub 2023 Apr 25. PMID: 37097526.

11. Guo Y, Wei X, Pei J, Yang H, Zheng XL. Dissecting the role of cannabinoids in vascular health and disease. J Cell Physiol. 2024 Nov;239(11):e31373. doi: 10.1002/jcp.31373. Epub 2024 Jul 10. PMID: 38988064.

12. Noël B, Ruf I, Panizzon RG. Cannabis arteritis. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S65-7. doi: 10.1016/j.jaad.2007.04.024. PMID: 18489050.

13. El Omri N, Eljaoudi R, Mekouar F, Jira M, Sekkach Y, Amezyane T, et al. Cannabis arteritis. Pan Afr Med J. 2017;26:53.

14. Adams MD, Earnhardt JT, Dewey WL, Harris LS. Vasoconstrictor actions of delta8- and delta9-tetrahydrocannabinol in the rat. J Pharmacol Exp Ther. 1976;196(3):649-656.

15. Desbois AC, Cacoub P. Cannabis-associated arterial disease. Ann Vasc Surg. 2013;27(7):996-1005.

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