Latest / The Science of Skin / Explaining the Microbiome with Dr Hilary Baldwin

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Explaining the Microbiome with Dr Hilary Baldwin · The Science of Skin

• 0:08
  SPEAKER_00: Hello and welcome to Skincare Confidential, the podcast supporting the Science of Skin Care Summit.
• 0:15
  SPEAKER_00: The goal of this podcast is to give you, the listener, a 360-degree view of the skincare industry.
• 0:22
  SPEAKER_00: And today, I, Dr.
• 0:24
  SPEAKER_00: Ted Lane, I'm your moderator today and your host.
• 0:26
  SPEAKER_00: I am so excited because I have one of my favorite, favorite people.
• 0:30
  SPEAKER_00: Her name is Dr.
• 0:31
  SPEAKER_00: Hilary Baldwin from New York.
• 0:33
  SPEAKER_00: Hillary, thank you so much for being with us.
• 0:35
  SPEAKER_01: It's such a pleasure, Ted.
• 0:36
  SPEAKER_01: Thank you very much for inviting me.
• 0:38
  SPEAKER_00: Oh gosh, this is great.
• 0:39
  SPEAKER_00: So Dr.
• 0:40
  SPEAKER_00: Baldwin is uh she she's an expert in many, many subjects, but we're gonna focus on the microbiome, and we'll actually touch on her expertise in acne and rosacea as well through the lens of the microbiome.
• 0:54
  SPEAKER_00: Um, but Dr.
• 0:55
  SPEAKER_00: Baldwin, Hillary, if you don't, can I call you Hillary?
• 0:57
  SPEAKER_00: Is that okay with everybody?
• 0:58
  SPEAKER_00: I think we know each other well enough, Deb.
• 0:59
  SPEAKER_00: Thank you.
• 1:00
  SPEAKER_00: I think we're good with that.
• 1:01
  SPEAKER_00: Okay.
• 1:01
  SPEAKER_00: So can you go through your story for us?
• 1:04
  SPEAKER_00: Like, how did you get to this point in your career and kind of your life as a dermatologist, now or researcher?
• 1:10
  SPEAKER_00: And even more than that, now you are kind of supporting and consulting with industry and helping doctors understand how to use all these new great products.
• 1:20
  SPEAKER_00: You just have a really interesting point in your career now.
• 1:22
  SPEAKER_00: And and just walk us through.
• 1:24
  SPEAKER_01: Well, that's that's a big stretch there.
• 1:27
  SPEAKER_01: And I you you mentioned before that that my early part of my story, which is kind of odd for for most people going into medicine, was was uh something that interested you.
• 1:37
  SPEAKER_01: My my parents were both opera singers and I was a ballet dancer.
• 1:40
  SPEAKER_01: So uh how I got to where I am now is kind of confusing to me too.
• 1:46
  SPEAKER_01: But um, you know, actually I decided to become a doctor because somebody told me I couldn't.
• 1:52
  SPEAKER_01: And from that day on, I decided to go to medical school.
• 1:54
  SPEAKER_01: He said, well, you know, the best you can be is a nurse.
• 1:56
  SPEAKER_01: And nurses are wonderful.
• 1:58
  SPEAKER_01: They work much harder than most doctors do, but uh that kind of annoyed me.
• 2:03
  SPEAKER_01: And so I went ahead to medical school, and then I decided to go into dermatology uh for no particularly good reason, other than I don't enjoy being in the hospital and I had good visual memory.
• 2:16
  SPEAKER_01: Um and I have a short attention span, so I kind of liked the small things.
• 2:21
  SPEAKER_01: You know, I wasn't interested in 10 hours in the operating room doing a triple A.
• 2:25
  SPEAKER_01: I wanted to cut and leave.
• 2:27
  SPEAKER_01: Um so I very much enjoy uh the the the uh it's not really the rapidity, but it's being able to converse with my patients and get to know them and enjoy them as human beings while taking care of their medicine.
• 2:43
  SPEAKER_01: And it it feels to me like that's the easiest thing.
• 2:46
  SPEAKER_01: It's easiest in dermatology to do to do that sort of thing.
• 2:49
  SPEAKER_01: I don't know if you agree with that statement, but yeah, that's funny.
• 2:52
  SPEAKER_00: I think all of us, especially you know, in that regard, a lot of us have a little bit of ADD where we're like, I don't think I could sit there in the operating room for three hours doing this.
• 3:01
  SPEAKER_00: I need to kind of, you know, go from patient to patient.
• 3:04
  SPEAKER_00: And and I agree, that's so much fun to to form that relationship with the patient, then meet their kids, then have their kids grow up in your practice.
• 3:12
  SPEAKER_00: I mean, that's where I'm like what 17 years in, and so now I'm starting to see my patient's children and they're getting older.
• 3:18
  SPEAKER_00: It's just it's very rewarding in that respect.
• 3:21
  SPEAKER_01: I I completely agree.
• 3:23
  SPEAKER_01: And you can do so many different things too.
• 3:25
  SPEAKER_01: Yeah, you know, there's enough time in your life to stay relevant and current in your practice as well as research, as well as embarking, as you mentioned, both of us on a uh a journey that takes us into pharma land, uh, which and and speaking land, which both of us uh uh prefer, actually.
• 3:44
  SPEAKER_01: I don't know about you, I shouldn't say it that way.
• 3:46
  SPEAKER_01: I really enjoy my relationship with pharma, my relationship at meetings and teaching people.
• 3:52
  SPEAKER_01: I went from teaching medical students to residents and now um my colleagues, and um, I just love that part of my life.
• 3:59
  SPEAKER_00: Yeah, you you of everyone that I know, Hillary, you have really had kind of well-defined parts of your career, it seems like, where you've done kind of the clinical practice, a ton of research, and now utilizing all of that to to focus on education, uh, both educating industry as well as educating your your fellow dermatologists.
• 4:20
  SPEAKER_00: And and I um I find that amazing.
• 4:23
  SPEAKER_00: I don't know anybody else that that does it like you do it.
• 4:27
  SPEAKER_01: Well, that's very sweet of you to say.
• 4:29
  SPEAKER_01: I just um, you know, I as you mentioned ATD, that that was a a very insightful thing to say.
• 4:35
  SPEAKER_01: I I think I do have it, although I've never been diagnosed.
• 4:37
  SPEAKER_01: But I love the fact that I don't do the same thing every day.
• 4:41
  SPEAKER_01: If I had to see patients eight hours a day, five days a week, I would probably shoot myself.
• 4:46
  SPEAKER_01: So I enjoy doing one thing in the morning and another entirely in the afternoon.
• 4:50
  SPEAKER_01: And I even enjoy driving from point A to point B and playing, you know, uh kill the pedestrian on my way.
• 4:57
  SPEAKER_01: So it's it's a it's just sort of a moment to to to enjoy life in the outside world before I continue on with my afternoon activity.
• 5:06
  SPEAKER_00: You your research though, you really focused on acne and rosacea, didn't you?
• 5:10
  SPEAKER_00: Right.
• 5:11
  SPEAKER_00: Yeah.
• 5:11
  SPEAKER_00: How did you do that?
• 5:12
  SPEAKER_00: How did how did that develop in your career?
• 5:14
  SPEAKER_01: Well, actually, I started off in keloids and hypertrophic scars.
• 5:18
  SPEAKER_01: When I first arrived at Down State, my chairman, as most chairmen do, said, well, you know, your job in the first couple of years is to find something you're passionate about, develop a niche, um, and start researching it and publishing it.
• 5:32
  SPEAKER_01: And I did.
• 5:34
  SPEAKER_01: Um, but you know, I was naive.
• 5:38
  SPEAKER_01: And what he failed to tell me is that you need to pick a niche that has a little bit of money in it, uh, some pharma support, somebody behind it, because ultimately you're going to be suffering from the lack of funding.
• 5:51
  SPEAKER_01: And um there's nobody really looking into keloids and hypertrophic scars uh at the pharmaceutical level.
• 5:59
  SPEAKER_01: So um he, my chairman, Alan Shelita, was arguably one of the gods of acne.
• 6:05
  SPEAKER_01: And so I decided to go in that route, you know, sort of do what daddy does, and um and take over the the uh the legacy that he started at Downstate being such an acne hotspot.
• 6:17
  SPEAKER_01: So that's how I started doing this, and then I realized that I really very much enjoyed acne and rosacea.
• 6:24
  SPEAKER_01: Um, you know, it's it's it's a can both of them are conditions that have such a great deal of psychological overlay, and you're almost as much a shrink as you are a dermatologist.
• 6:36
  SPEAKER_01: Uh if you do it well, if you take the time to listen to your patients and and make sure they're coping psychologically as well as physically with their ailments.
• 6:45
  SPEAKER_00: Yeah.
• 6:46
  SPEAKER_00: I I've heard you say this a few times, and I hope you don't mind me, don't mind me including this, but you know, you've said when you were when your children were younger and they were dealing with a bit of acne and they would come down in the morning, yes, you didn't you couldn't say anything about, hey, are you taking your medicine or using your creams for your acne because it would set them off and have a horrible day, and therefore you'd have a horrible day as well.
• 7:10
  SPEAKER_01: Exactly.
• 7:10
  SPEAKER_01: And you don't you don't realize I I'm not sure if every parent does this, but they come down in the morning and maybe it's from the warmth of the pillow or whatever, but their red, whatever red things they have on their face are particularly red.
• 7:23
  SPEAKER_01: And the first thought in your mind is, are they using their medications?
• 7:27
  SPEAKER_01: And I'm not sure if that's because we're dermatologists or because that's what all moms do.
• 7:31
  SPEAKER_01: But of course, saying to them at that moment, are you using your acne medicine is exactly equivalent to saying, Wow, your face looks awful this morning.
• 7:40
  SPEAKER_01: And yes, and set us all off on the wrong track.
• 7:43
  SPEAKER_01: Everybody had a lousy day, and you know, I had to learn to completely shut my mouth, especially uh first thing in the morning.
• 7:51
  SPEAKER_01: And it it started me off on doing a survey we did a couple years ago, finding out how much um agony and suffering there is in the family of acne patients, concerned about their future, concerned about bullying, concerned about them being the best that they could possibly be as a result of having relatively disfiguring acne.
• 8:12
  SPEAKER_01: And it turns out that moms in particular are terribly concerned about the acne limiting the child's ability to live up to their full potential.
• 8:23
  SPEAKER_01: Uh so it's not just the child, but the family as well.
• 8:27
  SPEAKER_00: Yeah.
• 8:28
  SPEAKER_00: It I'm always encouraged when a mom brings a young teenager in that is just starting on their acne journey because you know that, oh my gosh, I'm really gonna help this child.
• 8:39
  SPEAKER_00: I mean, first of all, the mom is doing something um just amazing for that child in terms of their self-esteem and confidence.
• 8:44
  SPEAKER_00: And the kid doesn't understand yet, right?
• 8:47
  SPEAKER_00: Usually not.
• 8:48
  SPEAKER_00: But you as a dermatologist, we know based on your research and others, that if you're able to control the acne uh, you know, starting off early, first of all, you can hopefully prevent it from getting worse, of course.
• 8:59
  SPEAKER_00: Second of all, you can prevent scarring, hopefully.
• 9:01
  SPEAKER_00: And third of all, the effect on the self-esteem and when that happens as a teenager can carry on into their adulthood, even after the acne gets better.
• 9:09
  SPEAKER_01: That's absolutely true.
• 9:10
  SPEAKER_01: You know, Alison Leighton from the UK wrote a great paper that I quote virtually daily called Scarred for Life.
• 9:18
  SPEAKER_01: And what it showed was even if there are no physical scars left over from your acne, that people who suffered from moderate to severe acne in their teenage years never quite got over it.
• 9:29
  SPEAKER_01: They still have remnants.
• 9:31
  SPEAKER_01: It's almost like PTSD from the acne that they had in teenage years.
• 9:35
  SPEAKER_01: Because as we know, when whenever you stand out in the crowd as a teenager, um, frankly, whether positive or negative, uh, your life is different, isn't it, than it would have been had you sort of been able to meld in with everybody else.
• 9:51
  SPEAKER_01: So, and and not just bullying.
• 9:54
  SPEAKER_00: It's yeah, the self-esteem.
• 9:55
  SPEAKER_00: I recently had a patient come in who was in her late 20s and had had acne as a child, been free of acne for a while and just probably hormonally started coming back a little bit.
• 10:05
  SPEAKER_00: Not not much, just a couple of bumps here and there.
• 10:07
  SPEAKER_00: And she came in crying, yes, saying, Yes, we have to get this under control.
• 10:10
  SPEAKER_00: This is reminiscent of my childhood and the bullying and everything that I dealt with, and I never want to go through that again.
• 10:16
  SPEAKER_00: And so we had to be very aggressive because I could see psychosocially what was happening to her.
• 10:22
  SPEAKER_01: Exactly.
• 10:23
  SPEAKER_00: Yeah, it was horrible.
• 10:24
  SPEAKER_00: Well, we could talk about acne forever, right?
• 10:27
  SPEAKER_00: Exactly.
• 10:27
  SPEAKER_00: Maybe we should have just done that.
• 10:29
  SPEAKER_00: But, you know, we're really um we I was wanting to focus on the microbiome.
• 10:33
  SPEAKER_00: Dr.
• 10:33
  SPEAKER_00: Baldwin has given uh lectures at the Science of Skincare Summit on the microbiome now for three years.
• 10:38
  SPEAKER_00: She's she's just a wonderful lecturer on that subject, as well as many others.
• 10:42
  SPEAKER_00: And uh, you know, I think we can really talk about the microbiome as it relates to acne as well, you know, and rosacea, probably more interesting in rosacea at this point.
• 10:53
  SPEAKER_00: But in terms of the microbiome, let's just define that for everybody, Hilary.
• 10:57
  SPEAKER_00: Could you just give us a definition of the microbiome quickly?
• 11:00
  SPEAKER_01: Well, the microbiome is not only the bacteria, but also the fungi and the viruses that live on the surface of the skin and their metabolic byproducts.
• 11:09
  SPEAKER_01: Uh and so the entire environment, not just the bacteria themselves, that's the microbiota.
• 11:16
  SPEAKER_01: Uh, but it's the whole environment uh that has been changed by virtue of the presence of the microorganisms.
• 11:24
  SPEAKER_01: So and and we recognize now, of course, 10 years ago we didn't know this.
• 11:28
  SPEAKER_01: Ten years ago, when you saw a cross-section of the epidermis, it ended at the stratum corneum.
• 11:33
  SPEAKER_01: And maybe the artist would throw in a couple of bugs sitting on top of it, but not because they were implying that the bugs had something to do with the functioning of the of the barrier, but uh just because they were there.
• 11:45
  SPEAKER_01: And the implication was that they were pathogens and they were bad guys.
• 11:48
  SPEAKER_01: Now we realize that that outer layer of the skin is not the stratumcorneum, but the microbiome layer, which plays a huge role in uh barrier dysfunction.
• 11:59
  SPEAKER_01: And so barrier dysfunction begets microbiome dysbiosis of the microbiome, and dysbiosis begets barrier dysfunction.
• 12:07
  SPEAKER_01: So they're they're very much interrelated.
• 12:10
  SPEAKER_01: And if we, for example, had a completely sterile stratum corneum, uh, the stratum corneum would not survive, the epidermis would not survive.
• 12:17
  SPEAKER_00: Interesting.
• 12:18
  SPEAKER_00: So you're pointing to the fact that there's an interplay between your skin and your immune system within your skin and the microbiome itself.
• 12:26
  SPEAKER_00: They actually communicate with each other.
• 12:28
  SPEAKER_00: And we have developed to have that communicate communicative skills and and um toe-like receptors and and all these different types of receptors that are in the epidermal layer to communicate with the microbiome because it does, in my very simplistic mind, it acts as a secondary immune system for our bodies.
• 12:46
  SPEAKER_01: Yes, it it you know, the the skin provides a place to live and moisture and food, and the bacteria occupy a niche and eat the nutrients that otherwise might be taken up by and eaten by pathogens.
• 13:00
  SPEAKER_01: It also the the healthy bacteria also reduce the pH of the skin down to the level at which the enzymes in the stratum corneum function at their best, and then, as you say, uh help with immune surveillance.
• 13:13
  SPEAKER_01: So the bacteria are a crucial part of the functioning.
• 13:17
  SPEAKER_01: And you know, we we do a lot of things to disrupt that, don't we?
• 13:20
  SPEAKER_01: Well, unfortunately we've got right back, which is kind of interesting.
• 13:24
  SPEAKER_00: And what's also interesting to me, there's so much interesting about the microbiome, but it's you know, you can take cultures across the different areas of the skin and have totally different um types or your microbiome will be will be uh there's different bacteria that will comprise the microbiome on the forehead versus the elbow versus the groin, for example.
• 13:44
  SPEAKER_00: Very different between the in the body, and then between individuals, it's very different as well.
• 13:49
  SPEAKER_00: So there's not like there's one microbiome that we're trying to fix, which I think makes it difficult.
• 13:55
  SPEAKER_01: Yeah, therein lies the rub, right?
• 13:57
  SPEAKER_01: Because uh, first of all, we don't know what a normal microbiome is because it differs, as you point out, between each uh amongst each patient, and then that particular patient with aging, and then that particular patient with where they happen to be.
• 14:11
  SPEAKER_01: Our microbiome will change if we're in uh Seattle in the rain or you know, Arizona in the in the dryness.
• 14:20
  SPEAKER_01: Um, so you know, if we're trying to repair the microbiome, if we're trying to normalize the microbiome, what is normal?
• 14:28
  SPEAKER_01: And as you pointed out, on body parts is different.
• 14:31
  SPEAKER_01: Do you know the body part that we're the most similar in?
• 14:33
  SPEAKER_01: I think this is funny.
• 14:35
  SPEAKER_01: The umbilicus.
• 14:36
  SPEAKER_01: Oh the most similar location across uh most people who have been uh evaluated.
• 14:43
  SPEAKER_01: I'm not sure why that is, but it's kind of an interesting tidbit to know.
• 14:47
  SPEAKER_00: Well, I've seen some pretty dirty belly buttons.
• 14:50
  SPEAKER_00: Yeah, right.
• 14:52
  SPEAKER_01: Which is why I think it's surprising.
• 14:54
  SPEAKER_01: Maybe it's just because it's so hidden.
• 14:56
  SPEAKER_01: I don't know.
• 14:57
  SPEAKER_00: Um and let's talk about the microbiome as it pertains to the hair follicle as well, because it, I mean, most of the microbiome, from my understanding, is actually contained within the actual hair follicle.
• 15:07
  SPEAKER_01: Right.
• 15:08
  SPEAKER_01: And you know, that's why you have to very be very careful when you look at studies that look at the microbiome of the skin, especially in terms of looking at acne, because acne, as we know, is a folliculocentric disorder.
• 15:20
  SPEAKER_01: And the disease is all in the pylosabaceous unit, it's not on the surface of the skin.
• 15:25
  SPEAKER_01: So if you do, if the study that you're looking at is doing a skin swab from the surface of the skin, it's going to find staph epidermis and malasseia and staph aureus and other organisms.
• 15:36
  SPEAKER_01: Um, and you know, C acne is sort of, I think it's 25% or something of the skin surface.
• 15:43
  SPEAKER_01: But in the follicle, it's 98% C acne and a little bit of malassesian, that's basically it.
• 15:50
  SPEAKER_01: So, what we really want to know when we're looking at the microbiome for acne is what is the follicle looking like.
• 15:58
  SPEAKER_01: And what's weird about this is that every place else in the body, diversity is a sign of skin health.
• 16:07
  SPEAKER_01: When the microbiome is very specific for one organism, that's a sign of a disease, like an abscess, right?
• 16:13
  SPEAKER_01: Culture an abscess, there's only one organism in it.
• 16:15
  SPEAKER_01: That's a bad thing.
• 16:17
  SPEAKER_01: So what we're looking for is a nice broad diversity of organisms.
• 16:20
  SPEAKER_01: But in the follicle, a healthy follicle has one organism growing in it, and that's the acnes.
• 16:27
  SPEAKER_01: Of course, they are different subtypes.
• 16:30
  SPEAKER_00: We're learning about, right?
• 16:31
  SPEAKER_01: Right.
• 16:32
  SPEAKER_01: And that's only been in the last 10 or 15 years that we've been learning about that.
• 16:36
  SPEAKER_01: So the diversity comes at the subtype level, not at the species level.
• 16:41
  SPEAKER_00: So we know that they are residential, right?
• 16:44
  SPEAKER_00: They're they're symbiotic organisms that live in part of our microbiome, the C acne's in particular.
• 16:49
  SPEAKER_00: We we interviewed um Thomas Hitchcock from Crown uh not too long ago, and he was talking about the C acne defendons, that that subspecies that he has utilized within his skincare line, which is absolutely not pathogenic.
• 17:02
  SPEAKER_00: In fact, he strongly believes that it maintains a healthy microbiome to the point that it actually reduces the um immunologic response and the skin, decreases inflammation and allows the skin to heal itself in many different ways.
• 17:17
  SPEAKER_00: So it's interesting that what we're learning now as we dive deeper into C acnes itself.
• 17:23
  SPEAKER_00: C acne for everybody is cutybacterium acne.
• 17:26
  SPEAKER_00: It is what we consider the bacteria that is not necessarily the cause of acne, but the the one that is the most residential in the hair follicle, and therefore we target that for acne and especially the immune system reaction to it leads to the inflammation.
• 17:40
  SPEAKER_00: So C acnes, that's what we're referring to.
• 17:43
  SPEAKER_00: Um and then in regards to, and you touched on this, Hillary, in regards to our treatments, uh we used to think that everything was about killing C acne, killing C acnes.
• 17:52
  SPEAKER_00: I'm not sure that's true anymore.
• 17:54
  SPEAKER_01: No, it's not.
• 17:56
  SPEAKER_01: Well, you know, the the the bottom line is that it's not possible to kill C acne permanently, right?
• 18:03
  SPEAKER_01: It we might be able to reduce the numbers, and yes, if the the subtype of C acnes that is inhabiting your follicle is is uh one that is going to cause a problem with acne and cause the inflammatory process that we know of is acne, uh then uh its presence is is a problem.
• 18:22
  SPEAKER_01: And if you could reduce the number, then the patient will get a little bit better.
• 18:27
  SPEAKER_01: But as soon as you stop the antibiosis, the numbers are gonna come right back to the to starting point.
• 18:32
  SPEAKER_01: So it's sort of futile, uh, frankly, to be using antibiotics.
• 18:36
  SPEAKER_01: Crucially important, of course, in somebody who has very inflammatory acne to get them better to begin with, it gets them over the hurdle, but then ultimately we're gonna have to use something else to control the condition, um, or else we're just gonna be right back on antibiotics all over again.
• 18:50
  SPEAKER_01: So I think you mentioned uh Thomas Hitchcock's uh concept, which is just fascinating.
• 18:56
  SPEAKER_01: So we we know that there's at least three subtypes of C acne, and one is associated with acne.
• 19:02
  SPEAKER_01: Now, we're back to the chicken and egg.
• 19:05
  SPEAKER_01: Did the acne cause predominance of the type 1A1 or did the 1A1 cause the acne?
• 19:13
  SPEAKER_01: Who knows?
• 19:14
  SPEAKER_01: But type 2, as you mentioned, called uh C acne defendants, is associated with skin health.
• 19:18
  SPEAKER_01: Now, he's gone the route of looking at it in terms of inflammation and skin aging.
• 19:23
  SPEAKER_01: I'm dying for him to look at it in acne.
• 19:26
  SPEAKER_00: Right.
• 19:26
  SPEAKER_01: What if we took uh one of those pore stripper pads that you can buy at the pharmacy and yanked out the contents of the follicle and then took his C acne defendons and vigorously rubbed it into the now empty pyloserbaceous unit?
• 19:43
  SPEAKER_01: Could you repopulate a type 1 acne prone subtype uh with the type 2 defendons healthy?
• 19:52
  SPEAKER_01: And could you potentially eradicate the disorder or at least temporarily make a patient better, far better this than using an antibiotic?
• 20:01
  SPEAKER_00: It's like the fecal transplant now the gut microbiome.
• 20:06
  SPEAKER_00: That's interesting.
• 20:06
  SPEAKER_01: And I I'm just dying for him to do that.
• 20:09
  SPEAKER_01: Um I was kind of bummed when I found out that he went in the direction of aging.
• 20:13
  SPEAKER_01: Um but um the interesting thing that he did with it though is uh he has a little genetic switch that stops the bacterium from multiplying, which I thought was amazingly brilliant.
• 20:26
  SPEAKER_01: I don't know how one would do that, first of all, but obviously he figured out how to do it.
• 20:30
  SPEAKER_01: But what that means is that we don't have to worry about rubbing C acne into our uh into our follicles when we have, like I do, artificial joints.
• 20:39
  SPEAKER_01: Because we're well aware, C acnes has been known to uh colonize artificial joints.
• 20:45
  SPEAKER_01: So I want to get rid of my acne, but I also want to keep my artificial knees.
• 20:49
  SPEAKER_00: Yeah.
• 20:50
  SPEAKER_00: It's you know, and I think a lot of people out there are concerned when we treat acne with systemic antibiotics, mostly tetracycline class antibiotics, because they feel like, oh, you're gonna lead to resistance, you're killing all these bacteria, when in fact we're really not utilizing them to kill the bacteria.
• 21:04
  SPEAKER_00: No.
• 21:04
  SPEAKER_00: And what we're utilizing them for is their anti-inflammatory effect to reduce the body's immune response.
• 21:10
  SPEAKER_00: They are potently anti-inflammatory, especially for the skin.
• 21:14
  SPEAKER_00: And so that's why you see us using them for two to three months at a time, just to maintain that anti-inflammatory effect as we use topical products then to start changing the the maturation and the multiplication of the skin cells, which are also involved in the acne process.
• 21:30
  SPEAKER_01: Right.
• 21:30
  SPEAKER_01: And and to stop sebum production too, with some of our new newer medications.
• 21:35
  SPEAKER_01: Absolutely.
• 21:36
  SPEAKER_01: So it's just a sort of a stopgap measure while these other medications are doing their job.
• 21:42
  SPEAKER_01: Yeah.
• 21:43
  SPEAKER_01: I I completely agree.
• 21:44
  SPEAKER_01: And you mentioned that we're using it for anti inflammation, and which is why sometimes we use anti inflammatory dystoxycycline as opposed to full dose, um, to give you that nice anti uh anti inflammatory activity without uh causing uh uh Resistant organisms.
• 22:02
  SPEAKER_00: So that's a great segue, actually, as we can move into rosacea.
• 22:05
  SPEAKER_00: Thank you for that.
• 22:06
  SPEAKER_00: So we utilize low-dose doxycycline, and pretty soon we'll have a low-dose minacycline available as well to treat rosacea, which we don't believe is related necessarily to a bacterium, although there maybe that's coming into a little bit of discussion as well as we think about a certain bacteria that resides on the mites.
• 22:27
  SPEAKER_00: But uh otherwise, yes, absolutely.
• 22:29
  SPEAKER_00: We use the low-dose antibiotic, the low-dose doxycycline to reduce inflammation.
• 22:33
  SPEAKER_00: It's a slow release over time.
• 22:35
  SPEAKER_00: Um, but let let's let's kind of go into rosacea.
• 22:38
  SPEAKER_00: We don't we don't have much time.
• 22:40
  SPEAKER_00: We've been just enjoyed our discussion so much.
• 22:42
  SPEAKER_00: So um rosacea.
• 22:44
  SPEAKER_00: Okay, so rosacea absolutely has uh altered microbiome as well and an altered immune system response to the microbiome.
• 22:52
  SPEAKER_00: Can you just go into that a little bit for us?
• 22:55
  SPEAKER_01: Sure.
• 22:56
  SPEAKER_01: We call it a chronic inflammatory disease with neurovascular dysregulation, is the total expression that I like to use.
• 23:03
  SPEAKER_01: So uh as you mentioned, you know, the bacteria obviously are hanging out on the skin still, despite the fact that we don't think they're directly causative for rosacea, but maybe it's the absence of causation.
• 23:16
  SPEAKER_01: For example, C acnes is dramatically and significantly reduced in the follicle of patients with rosacea.
• 23:23
  SPEAKER_01: So is it the absence of C acnes that allows for uh an increase in the colonization by other organisms that we do know, like you mentioned Bacillus oloroneus, maybe staph epidermidus, uh, maybe Demodex.
• 23:37
  SPEAKER_01: Who knows what is actually precipitating all of this?
• 23:42
  SPEAKER_01: But there may still be a bacterial element involved in all of this, uh, which may be why, for example, topical menacycline is helpful in the treatment of rosacea.
• 23:52
  SPEAKER_01: But for the most part, we're looking for anti-inflammatory drugs like anti-inflammatory dose doxycycline.
• 23:58
  SPEAKER_01: And if I may uh nitpick just a tad, Ted, I don't consider this to be a low-dose antibiotic.
• 24:05
  SPEAKER_01: I consider it to be a non-antibiotic.
• 24:08
  SPEAKER_01: Low dose antibiotics in in acne are 50 milligrams of doxy or minnow as opposed to 200.
• 24:15
  SPEAKER_01: But this at 40 milligrams modified release is a, from what we can tell, a non-antibiotic dose of the drug.
• 24:22
  SPEAKER_01: So it does not pressure the bacteria to mutate and become resistant.
• 24:27
  SPEAKER_00: It it doesn't reach the dose that that could kill the bacteria.
• 24:31
  SPEAKER_00: Right.
• 24:31
  SPEAKER_00: Okay, so that's that's actually a great point.
• 24:33
  SPEAKER_00: Thank you for that.
• 24:34
  SPEAKER_00: So um you mentioned Demodex.
• 24:36
  SPEAKER_00: We know that in some rosacea patients, the Demodex mite, there is overgrowth.
• 24:40
  SPEAKER_00: Uh, in some there are not, which makes it very confusing.
• 24:44
  SPEAKER_01: Yes.
• 24:44
  SPEAKER_00: You mentioned Bacillus oloroneus, which is a bacterium that that lives on the mite itself, that in it may not be the mite that's pathogenic, it may be the that bacteria.
• 24:54
  SPEAKER_00: Still so much for us to figure out with rosacea.
• 24:57
  SPEAKER_01: You know, we don't even know patients have all the symptoms and signs of rosacea being a barrier deficiency disorder, but we still have not examined ceramide levels in rosacea.
• 25:09
  SPEAKER_01: We know about it in atopic dermatitis and psoriasis and acne and obsessive-compulsive hand washing, but we still don't have that answer in rosacea.
• 25:17
  SPEAKER_01: I'm sure ceramide NP is reduced in rosacea, but clearly a barrier deficiency disorder.
• 25:24
  SPEAKER_01: And once again, we have that darn chicken and egg thing.
• 25:27
  SPEAKER_01: Is it the barrier deficiency that's presenting as rosacea or the other way around?
• 25:33
  SPEAKER_01: But when we fix the barrier in rosacea patients, their rosacea gets better even without treatment.
• 25:40
  SPEAKER_01: And poor skin care wreaks havoc on the skin of patients with rosacea.
• 25:46
  SPEAKER_01: So it's important for both acne and rosacea that no patient leaves the office until we've discussed good quality skin care.
• 25:53
  SPEAKER_00: Right.
• 25:53
  SPEAKER_00: And you mentioned the ceramides.
• 25:54
  SPEAKER_00: So for everybody listening, ceramides, cholesterol, and free fatty acids are part of that lipid bilayer that mortar between the bricks of the stratum corneum.
• 26:03
  SPEAKER_00: So the stratum corneum is the outermost layer of the skin beside below the microbiome or incorporated with the microbiome in some ways.
• 26:11
  SPEAKER_00: And it is comprised of dead skin cells that are held together by a glue.
• 26:14
  SPEAKER_00: That glue is comprised of that ceramides, cholesterol, and free fatty acids, and that acts as a waterproof barrier for your skin.
• 26:21
  SPEAKER_00: Although there are some things that are allowed in and some things that are allowed out, otherwise, it's what protects you from the environment.
• 26:27
  SPEAKER_00: And so when we talk about barrier insufficiency, for example, it's that outermost layer which is compromised and allowing our skin, causing our skin to lose hydration.
• 26:37
  SPEAKER_00: And uh unfortunately that leads to dryness and inflammation and scratching and itching and everything that you may associate with your barrier not being uh fully prepared to deal with the environment.
• 26:50
  SPEAKER_00: Is that fair, Hillary?
• 26:52
  SPEAKER_01: Absolutely.
• 26:52
  SPEAKER_01: I mean, the stratum corneum is supposed to keep everything out and keep us in.
• 26:56
  SPEAKER_01: And in both of these conditions, it's not doing that.
• 26:59
  SPEAKER_00: Yeah, yeah.
• 27:00
  SPEAKER_00: And we have we there's been some research that's come out many years ago that show that you you can actually replace the ceramides within that mortar.
• 27:07
  SPEAKER_00: Um, and you can actually cause the skin by by applying ceramides to the skin, you can actually cause the skin cells to produce more ceramides itself as well.
• 27:15
  SPEAKER_00: So it's it's actually a signal to help the skin heal itself in some ways.
• 27:20
  SPEAKER_00: So that's why ceramides are so important.
• 27:24
  SPEAKER_00: Uh, and and you know, a ceramide-containing moisturizer can be very helpful in patients with barrier insufficiency, whether it's rosacea, we know patients with acne have impaired barriers, which is counterintuitive, I think, to a lot of patients who don't think they need to moisturize because they feel so oily.
• 27:39
  SPEAKER_00: Um but uh actually, if we let's let's go into that real quick, the kind of crossing over um the the oil of that is produced in acne patients, Hillary.
• 27:51
  SPEAKER_00: Can you talk about that a little bit?
• 27:52
  SPEAKER_00: I know that's not part of the microbiome, but it's all part and parcel of what we're talking about.
• 27:56
  SPEAKER_01: It's all interconnected.
• 27:57
  SPEAKER_00: Yeah.
• 27:58
  SPEAKER_01: Yeah.
• 27:58
  SPEAKER_01: So I mean, it it the oil is called sebum and it's within the follicles.
• 28:02
  SPEAKER_01: So uh some patients who there are plenty of acne patients who have oily skin, but there are also plenty of acne patients who have dry skin and patients who have terribly oily skin without acne.
• 28:16
  SPEAKER_01: So the oiliness on the surface of your the skin does not actually cause acne or prevent acne from occurring.
• 28:24
  SPEAKER_01: So you might need moisturization even though your face feels a little bit greasy because it's completely different.
• 28:33
  SPEAKER_01: Sebum is not a moisturizer.
• 28:36
  SPEAKER_01: And you still need, it doesn't have ceramides in it, for example.
• 28:39
  SPEAKER_01: So you still need your barrier to be repaired, even if you might feel a little greasy.
• 28:44
  SPEAKER_01: So the way I look at it is the idea is to wash off all the greasiness that you feel and then apply a quality moisturizer that contains things like niacinamide and ceramides to help replenish the healthy portion, as you mentioned, of the stratum corneum and allow those ceramides to get into the skin and incorporate themselves in a healthy way.
• 29:06
  SPEAKER_00: We know that the sebum that is produced by patients with acne is altered, right?
• 29:09
  SPEAKER_00: There's a higher squalene content, it can be pro-inflammatory as well.
• 29:13
  SPEAKER_00: We also know that sebum can undergo lipid peroxidation, which is kind of causes oxidative stress uh and and leads to more inflammation as well.
• 29:24
  SPEAKER_00: Um so there are many reasons why you should not consider your own, if you have acne, your own sebum, the own oiliness on your face, don't consider that a moisturizer.
• 29:33
  SPEAKER_00: It actually can be harmful and needs to be removed in a gentle way so that you're not stripping again, impairing the barrier with foaming cleansers, with over-stripping the skin with exfoliation as well.
• 29:45
  SPEAKER_00: Can't stress that enough, right, Hillary?
• 29:47
  SPEAKER_01: Absolutely true.
• 29:48
  SPEAKER_01: And you know, I think sometimes our acne patients, they're they're vaguely aware of the fact that there is a bacterium involved in acne.
• 29:55
  SPEAKER_01: So they reach for a soap which says antibacterial on it.
• 29:58
  SPEAKER_01: And antibacterial soaps traditionally have a pH which is way high, 10 to 12, which just destroys the stratum of corneum.
• 30:08
  SPEAKER_01: The skin, the skin wants to be at four to six, and here we are using 10 to 12, and uh it's just uh very destructive, and it's a great idea, uh, but that's not how we go about killing C acnes, which again is hiding inside the follicle.
• 30:24
  SPEAKER_01: So soap doesn't really help all that much anyway.
• 30:27
  SPEAKER_00: You know, we talk about the acid mantle of the skin, which is that that normal pH of four to six that Hillary just talked about.
• 30:34
  SPEAKER_00: Your skin cells, the biology of your skin works best at that pH.
• 30:39
  SPEAKER_00: It produces the correct ceramides, it just works best at that pH.
• 30:42
  SPEAKER_00: So when you alter that, when you don't have a pH balanced cleanser, it tilts the skin into not only dysbiosis, but also into a state of repair, which can be inflammatory as well.
• 30:53
  SPEAKER_00: So uh we've we've laid down a lot of pearls today, haven't we, Hilary?
• 30:57
  SPEAKER_01: We have indeed.
• 30:59
  SPEAKER_00: We are out of time.
• 31:00
  SPEAKER_00: Uh, we spoke a little bit about the microbiome, but we spoke a lot about other stuff as well.
• 31:04
  SPEAKER_00: Um, we need to do this again.
• 31:05
  SPEAKER_00: That was so much fun.
• 31:07
  SPEAKER_01: My pleasure.
• 31:08
  SPEAKER_00: Thank you.
• 31:09
  SPEAKER_00: Uh okay, guys.
• 31:10
  SPEAKER_00: Well, this is this uh Skincare Confidential, the podcast supporting the Science of Skincare Summit.
• 31:14
  SPEAKER_00: I am Dr.
• 31:15
  SPEAKER_00: Ted Lane.
• 31:16
  SPEAKER_00: My uh guest today is Dr.
• 31:17
  SPEAKER_00: Hilary Baldwin.
• 31:18
  SPEAKER_00: Thank you again.
• 31:19
  SPEAKER_00: Don't forget to uh to to please give us five stars to subscribe and to share this with your uh your your people.
• 31:27
  SPEAKER_00: And um we look forward to uh seeing you again.
• 31:31
  SPEAKER_00: Thanks for