Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome in Adolescents: A Case Series

Abstract

Cannabinoid hyperemesis syndrome (CHS) is an underrecognized diagnosis among adolescents. In the adult literature, it is characterized as nausea, vomiting, and abdominal pain in patients with chronic marijuana use. CHS is often refractory to the standard treatment of nausea and vomiting. Unconventional antiemetics, such as haloperidol, have been successful in alleviating symptoms; however, even 1 dose of haloperidol can lead to grave adverse effects, such as dystonia, extrapyramidal reactions, and neuroleptic malignant syndrome. The use of topical capsaicin cream to treat CHS has been well described in the adult literature. This treatment is cost-effective and is associated with few serious side effects. Here, we describe 2 adolescent patients with nausea, vomiting, and abdominal pain in the setting of chronic cannabis use whose symptoms were not relieved by standard antiemetic therapies, but who responded well to topical capsaicin administration in our pediatric emergency department. We also discuss the pathophysiology behind capsaicin's efficacy. These are the first reported cases in which capsaicin was successfully used to treat CHS in pediatric patients.

Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome

“…Limited responses to abortive antiemetic medications are often mentioned in articles on CHS, while others report excellent responses to parenteral benzodiazepines (GABA A agonists) such as lorazepam, the neuromodulator olanzapine, or the potent D 2 antagonist haloperidol—an agent with overlapping pharmacology to many commonly used antiemetic including prochlorperazine and metoclopramide . Prior studies have proposed selective benefits of topical capsaicin treatments for acute CHS attacks, potentially acting in similar fashion as hot baths . However, similar treatments have not been employed for patients with CVS without cannabis exposure, so the specificity of these benefits for CHS is uncertain.…”

“…4 One retrospective study commented that "the ability of hot water bathing and showering to mitigate symptoms" is the most defining characteristic of CHS while a second small series commented that these behaviors are "pathognomonic" for CHS. 6,182 However, nearly 10% of CHS patients do not report this behavior even in articles which claim hot bathing to be essential for diagnosis. 4,43,174 The specificity of this behavior was rejected in a recent comparison study in which 48% of CVS patients with no cannabis use reported symptom relief with hot baths or showers compared to 72% who used cannabis.…”

Cannabinoid Hyperemesis

“…It should be noted that in the case of CHS, compulsive showering in hot water is not an anxiety disorder but rather a learned behavior that the patient develops to relieve symptoms [94]. Similar to hot water, capsaicin provides symptomatic relief of CHS [95-97] but not other vomiting disorders. Topical capsaicin has been advocated for use as a diagnostic tool for CHS to differentiate it from other vomiting syndromes [36].…”

“…In both cases, topical capsaicin provided symptomatic relief in about 30 min. Both patients reported a burning sensation where the capsaicin was applied but were satisfied with the results [97]. …”

“…A summary of these studies appears in Table 2 [6, 7, 10, 19, 22, 54, 94, 97, 99, 101, 105, 111, 113, 114, 116, 117, 121, 126, 127, 132-173]. …”