Latest / The Science of Skin / Jennifer Fugo, MS, LDN, CNS: The gut-skin connection and treating chronic skin diseases.

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Jennifer Fugo, MS, LDN, CNS: The gut-skin connection and treating chronic skin diseases. · The Science of Skin

• 0:09
  SPEAKER_00: Hi, I'm Dr.
• 0:10
  SPEAKER_00: Patty Ferris.
• 0:11
  SPEAKER_00: I'm a board certified dermatologist, and I'm your co-host for this episode of Skin Care Confidential.
• 0:16
  SPEAKER_00: As most of you know, Skin Care Confidential is an outreach of our medical meeting, the Science of Skin Care Summit, and I'm super excited today to be able to announce that we have our dates for 2024, November the 8th through the 10th.
• 0:29
  SPEAKER_00: That's a Friday through Sunday in Austin, Texas, at the Fairmont Hotel.
• 0:33
  SPEAKER_00: I'm hoping our guests today will be able to attend.
• 0:35
  SPEAKER_00: We're going to talk about that in a few minutes.
• 0:37
  SPEAKER_00: But I want to welcome a new friend of mine, Jennifer Fugo, to the show.
• 0:42
  SPEAKER_00: Thank you so much for having me.
• 0:44
  SPEAKER_00: I'm super excited.
• 0:45
  SPEAKER_00: I'm going to read your bio.
• 0:46
  SPEAKER_00: It's pretty intense, so here I go.
• 0:49
  SPEAKER_00: She holds a master's degree in human nutrition from the University of Bridgeport.
• 0:53
  SPEAKER_00: She's a licensed dietitian, nutritionist, and certified nutritional specialist.
• 0:58
  SPEAKER_00: She's the host of her own podcast, Healthy Skin Show, with over a million downloads.
• 1:04
  SPEAKER_00: Congratulations.
• 1:06
  SPEAKER_00: Thank you.
• 1:06
  SPEAKER_00: Super successful.
• 1:08
  SPEAKER_00: We aim to be you someday.
• 1:10
  SPEAKER_00: That's so exciting.
• 1:11
  SPEAKER_00: She has a very interesting niche in nutrition, and she has helped empower adults who unfortunately have failed conventional medicine to beat chronic skin diseases and unending gut challenges.
• 1:24
  SPEAKER_00: And as dermatologists, these are kinds of patients that we face all the time.
• 1:29
  SPEAKER_00: She regularly works with patients who have eczema, psoriasis, rosacea, dandruff, and hives, and has clientele that ranges from regular people to celebrities, of course, and professional athletes.
• 1:42
  SPEAKER_00: She also works with some very notable dermatologists.
• 1:45
  SPEAKER_00: Dr.
• 1:45
  SPEAKER_00: Peter Leo gave me a big double thumbs up on Jen Fugo and said she's extremely knowledgeable.
• 1:51
  SPEAKER_00: And for those of you who don't know Peter, and most dermatologists do, he runs an integrative eczema center in Chicago.
• 1:58
  SPEAKER_00: And he's one of the most well-respected authorities on atopic dermatitis in the United States and around the world, quite frankly.
• 2:05
  SPEAKER_00: Also interesting, Jennifer, I want to talk to you about this.
• 2:07
  SPEAKER_00: You have your own skincare line.
• 2:09
  SPEAKER_00: I did check out your website, the Quell Shop, and a line of supplements.
• 2:13
  SPEAKER_00: So this is all stuff I'm super interested in.
• 2:16
  SPEAKER_00: But we have to start with you telling us how in the world did you get into this interesting niche of nutrition, dermatologic diseases.
• 2:26
  SPEAKER_02: Well, I will say that I have to credit some of this to my dad, who was a medical doctor and he was actually an ophthalmic surgeon.
• 2:34
  SPEAKER_02: So I had, I guess because it's a family business, you know, you had to work as a kid in the family practice.
• 2:41
  SPEAKER_02: And when I graduated college, there weren't a whole lot of jobs at the time.
• 2:45
  SPEAKER_02: So I went back home to work at the family practice again.
• 2:49
  SPEAKER_02: And I noticed something about his patients.
• 2:53
  SPEAKER_02: So obviously it's not exactly skin related, but I did start to realize just generally how sick many of his patients were.
• 3:01
  SPEAKER_02: I started asking questions.
• 3:03
  SPEAKER_02: What did what do you eat?
• 3:04
  SPEAKER_02: Um, you know, what are you eating before bedtime?
• 3:07
  SPEAKER_02: A lot of his patients were diabetic.
• 3:09
  SPEAKER_02: I was just curious because some of them were so, so ill.
• 3:14
  SPEAKER_02: And that's where my interest, I would say, in nutrition in general started in realizing that many of these individuals did not understand basic nutritional concepts, that they were given honestly very poor advice, like being told that they could just drink diet soda all day and there would be no negative impact to that and not drink any water.
• 3:37
  SPEAKER_02: Or diabetic patients being told to eat what is essentially a very, very high carb meal before bed.
• 3:46
  SPEAKER_02: I mean, I it was just there were so many things that were confusing to me.
• 3:50
  SPEAKER_02: And I also had my own health challenges.
• 3:52
  SPEAKER_02: I had a lot of gut issues as a kid and a teenager, and then into my 20s, I started to realize that there was a connection between what I ate and how I was feeling.
• 4:01
  SPEAKER_02: And so that's really what prompted me to go into nutrition.
• 4:04
  SPEAKER_02: I started as a health coach and then very quickly was like, this is not the scope of practice that I want to work in.
• 4:11
  SPEAKER_02: So I went back to the University of Bridgeport to get my master's in human nutrition.
• 4:16
  SPEAKER_02: And that's where this whole journey began.
• 4:19
  SPEAKER_02: And now I do have the pleasure of being able to work in a team environment with people's dermatologists, their PCPs, and being able to help that individual advocate for themselves.
• 4:32
  SPEAKER_02: Because I realized that my specialty is different than the physicians.
• 4:36
  SPEAKER_02: My dad, I would look at the patient's um pre-op blood work and I'd be like, oh dad, see this, this.
• 4:42
  SPEAKER_02: And he's like, how do you know that?
• 4:45
  SPEAKER_02: He just they didn't learn how to look at blood labs like I was because we learn nutritional biochemistry.
• 4:52
  SPEAKER_02: So there's a lot of benefits to both.
• 4:55
  SPEAKER_02: And I think that the other factor, I ended up with um disidroidic eczema on my hands when I started grad school.
• 5:02
  SPEAKER_02: And actually before that, when I got married in 2010, I developed hydrodenitis supportiva in my armpits, which was very scary because I actually thought it was cancer originally because of the lumps.
• 5:14
  SPEAKER_02: And so I have had these two issues.
• 5:17
  SPEAKER_02: Uh, fortunately, the HS is in remission thanks to uh laser hair removal.
• 5:22
  SPEAKER_02: I had it done early and that really helped.
• 5:25
  SPEAKER_00: But absolutely does.
• 5:27
  SPEAKER_02: Um, that was what prompted me to have an interest in this.
• 5:31
  SPEAKER_02: And I didn't explicitly go into my nutrition practice when I graduated with the idea of working with these particular subset of individuals.
• 5:41
  SPEAKER_02: But I think when people heard my story, they felt like I could relate to them, that I understood what they were going through.
• 5:47
  SPEAKER_02: And so it just grew and grew into what it is today.
• 5:50
  SPEAKER_02: And I just have this burning curiosity to connect dots.
• 5:54
  SPEAKER_02: And I felt like, what if we connected all these great minds that some are dermatologists, some are gastroenterologists, some are nutrition professionals, like all over the place?
• 6:02
  SPEAKER_02: We start building this collective knowledge base and see if that can help people actually get better results, get better faster.
• 6:10
  SPEAKER_02: I mean, I think that's ultimately the goal is to reduce the level of suffering that people are going through.
• 6:15
  SPEAKER_02: And so that's how my podcast was born.
• 6:18
  SPEAKER_00: And so interesting.
• 6:19
  SPEAKER_00: So, how do you approach a patient, say somebody like a Dr.
• 6:23
  SPEAKER_00: Leo, who's an expert, and we know he's prescribed all the right medicines and given the patients every bit of medical advice that they could receive and appropriate and the like.
• 6:34
  SPEAKER_00: How do you approach a patient like that?
• 6:37
  SPEAKER_00: What sort of testing do you do and evaluation do you do?
• 6:40
  SPEAKER_02: Well, I think the first step is looking at the patient as, you know, from this nutritional standpoint.
• 6:48
  SPEAKER_02: I think that's one of the first pieces that I understand some derms feel very nervous about.
• 6:54
  SPEAKER_02: They're very hesitant sometimes to run labs, but there is a plethora of information online, especially in research, identifying specific nutrient insufficiencies or outright deficiencies with exacerbations in skin issues like itching, et cetera.
• 7:11
  SPEAKER_02: And so knowing what nutrients to actually test can be a godsend because sometimes we pick up significant deficiencies that I mean, I'm not running like I'm not asking for specialty labs.
• 7:28
  SPEAKER_02: It's it's very basic things that could be really beneficial to that person and could drastically help reduce the amount of like stero topical steroids they might need because they're not as itchy.
• 7:41
  SPEAKER_02: So that's number one, um, looking for those specific things.
• 7:45
  SPEAKER_02: Number two, I do like to know what their bowel movement frequency is.
• 7:49
  SPEAKER_02: I know that might be like a weird question to ask if you're not asking it, but I do find that if someone is chronically constipated, um, they tend to do worse.
• 8:01
  SPEAKER_02: And so helping to get stool moving along at a more normalized rate, which ideally is one to three times a day, can actually reduce some people's itchiness.
• 8:12
  SPEAKER_02: Um, and there's a variety of reasons for why that may be happening, but I do think it's a worthwhile question to ask.
• 8:20
  SPEAKER_02: It also could pick up if there are some underlying GI issues that perhaps they need to either work with a nutrition specialist like myself or a go see a GI doctor.
• 8:31
  SPEAKER_02: Um, and in some of these conditions, like psoriasis, especially, we know that there are eerie ties to how the gut microbiome tends to look, in that it has this sort of like IBD picture of like at least the gut microbiome.
• 8:45
  SPEAKER_02: Um, and then also asking how much protein that patient is eating, my bare minimum is 70 to 80 grams a day, usually split or spread across the day.
• 8:56
  SPEAKER_02: Most people, especially women, do not eat that much protein.
• 9:01
  SPEAKER_02: And part of it's a lot.
• 9:02
  SPEAKER_02: It it's actually not.
• 9:04
  SPEAKER_02: That's the minimum.
• 9:05
  SPEAKER_00: How do you get how do you get to no?
• 9:07
  SPEAKER_00: I know it's it's not, it's what you but how do you get a female to get that much protein in?
• 9:12
  SPEAKER_02: 100%.
• 9:13
  SPEAKER_02: So um, I think practical knowledge about first of all, I I want to acknowledge that nobody knows what a gram looks like.
• 9:20
  SPEAKER_02: Let's just be honest.
• 9:21
  SPEAKER_01: Good point.
• 9:21
  SPEAKER_01: Yeah.
• 9:22
  SPEAKER_01: So would you tell me?
• 9:23
  SPEAKER_01: What is a gram of protein?
• 9:24
  SPEAKER_02: Right.
• 9:24
  SPEAKER_02: So, uh well, that's the problem.
• 9:27
  SPEAKER_02: It's a unit that we don't know what it looks like.
• 9:31
  SPEAKER_02: So it's how much.
• 9:32
  SPEAKER_02: Right.
• 9:33
  SPEAKER_02: So basically, we have to say what can we practically do to help someone figure out how much protein they're consuming.
• 9:39
  SPEAKER_02: So one, there's two really great tools that you can have patients use that are free.
• 9:43
  SPEAKER_02: There's chronometer.com and myfitnesspal.com.
• 9:46
  SPEAKER_02: They can go, they can track their food intake for like three to five days, just looking.
• 9:51
  SPEAKER_02: Obviously, if this is somebody who has an e eating disorder history, probably not a good idea.
• 9:55
  SPEAKER_02: But if they don't and they can go and do that, they can see for themselves how much protein they're eating over the course of three to five days, which is a pretty good average.
• 10:04
  SPEAKER_02: Um, so I like to practically teach people what that looks like.
• 10:07
  SPEAKER_02: So, first of all, every egg, so one egg is six grams of protein.
• 10:11
  SPEAKER_02: So if you're only eating one egg in the morning, that's really not enough.
• 10:15
  SPEAKER_02: Now we want to look at, you know, could we do like some turkey sausage or chicken sausage or something like that?
• 10:21
  SPEAKER_02: Can we up it to maybe two eggs or three eggs?
• 10:25
  SPEAKER_02: How can we find more protein in different things?
• 10:28
  SPEAKER_02: Can we can the can the patient tolerate collagen, for example?
• 10:32
  SPEAKER_02: Usually a serving size of collagen is 11 to 14 grams.
• 10:35
  SPEAKER_02: It can't be used as like your sole source because it's not a complete protein, but it can certainly be a supplemental source.
• 10:43
  SPEAKER_02: Could be added to tea, could be added to their coffee, right?
• 10:46
  SPEAKER_00: That's really smoothies, people added everything.
• 10:49
  SPEAKER_02: And then looking throughout the day at the different snacks, I think the other problem, and this is just um a reflection of where we are in the um sort of plant plant-based craze, is that people tend to not realize that, and then when I say people, I mean specifically patients, don't understand that some of these alternatives for that are like protein sources, like nuts.
• 11:12
  SPEAKER_02: While yes, nuts have protein, they are predominantly a fat source.
• 11:15
  SPEAKER_02: It's a fatty protein.
• 11:17
  SPEAKER_02: So you're having a drastic increase of calories if you're relying on like nuts and seeds entirely for your protein.
• 11:25
  SPEAKER_02: If you go to beans, well, that's great.
• 11:27
  SPEAKER_02: They're not a complete protein.
• 11:28
  SPEAKER_02: You have to pair them with a grain.
• 11:30
  SPEAKER_02: Um, but beans are also a carby or starchy protein.
• 11:34
  SPEAKER_02: It's not to say they're bad.
• 11:36
  SPEAKER_02: I am a big fan of being an omnivore and eating a variety of different things, but we just I think that it underscores the necessity of looking for variety in your food.
• 11:48
  SPEAKER_02: And so, you know, I'm like, okay, uh beef patty, a quarter pound is approximately like 23 grams.
• 11:55
  SPEAKER_02: Look at your protein powders, different things that are practical that people can learn how much is in something and they can begin to eyeball it.
• 12:04
  SPEAKER_02: So that's that's the uh really third thing.
• 12:07
  SPEAKER_02: And then I would say if we get into like a little bit more nitty-gritties, because I know that you were like, let's talk a little bit about certain skin issues.
• 12:14
  SPEAKER_02: Um, rosacea has a huge connection with SIBO or small intestine bacterial overgrowth.
• 12:19
  SPEAKER_02: About 77% from the literature is saying that SIBO is present.
• 12:24
  SPEAKER_02: So if that's where we do need to ask if there are potential GI symptoms, and they may need a referral to a gastroenterologist.
• 12:33
  SPEAKER_02: Um, so that's really important.
• 12:35
  SPEAKER_02: Eczema, obviously, we have nutrient deficiencies that can worsen things.
• 12:39
  SPEAKER_02: So we need to look for deficiencies in zinc, iron, B12, folate, vitamin D, and vitamin A.
• 12:46
  SPEAKER_02: And psoriasis also has its own subset of nutrient deficiencies that are pretty similar to eczema, but they also need to be evaluated for non-alcoholic fatty liver disease by looking at their liver enzymes, so the ALT and AST, but also looking at GGT, that's another enzyme that usually has to be run on its own, can be very helpful.
• 13:09
  SPEAKER_02: The lipid panel, and then of course their hemoglobin A1C to see what their blood sugar balance looks like.
• 13:14
  SPEAKER_02: So I think those are some really great basics.
• 13:17
  SPEAKER_02: Um, and obviously, if someone isn't, if you're if you're not comfortable looking at those levels, uh, you know, there are others that you can obviously refer patients to who like we do this on a regular basis, but these are important.
• 13:32
  SPEAKER_00: So you did mention the gut microbiome, and I was familiar with the small intestinal bowel overgrowth with the rosacea patient studies.
• 13:41
  SPEAKER_00: How do you test the gut microbiome in these patients?
• 13:45
  SPEAKER_02: I like to use um stool testing.
• 13:48
  SPEAKER_02: Um, so I'm pretty specific.
• 13:51
  SPEAKER_02: I don't know if you're allowed to mention the different types of tests or names.
• 13:55
  SPEAKER_00: You certainly can.
• 13:55
  SPEAKER_00: I guess we mentioned a few.
• 13:56
  SPEAKER_02: Yeah, so there's the GI Map from Diagnostic Solutions, there's the GI FX from Genova Labs.
• 14:05
  SPEAKER_02: Genova Diagnostics, I think is the name.
• 14:08
  SPEAKER_02: Um, those are probably the two better ones.
• 14:11
  SPEAKER_02: Um I think the GI FX is a little nicer in that it always checks for H.
• 14:16
  SPEAKER_02: pylori or Helicobacter pylori.
• 14:19
  SPEAKER_02: It's not an add-on um that you have to pay for like it is with the GI FX.
• 14:24
  SPEAKER_02: So I tend to prefer the GI FX, but I don't, I don't have any relationship with them or anything.
• 14:30
  SPEAKER_02: I just find it to be a more useful tool.
• 14:31
  SPEAKER_00: Or the better tasks.
• 14:33
  SPEAKER_02: Um and so that's generally how I do that.
• 14:36
  SPEAKER_02: Now, granted, I'm also asking a lot of questions about are is the person belching?
• 14:41
  SPEAKER_02: Do they have indigestion?
• 14:43
  SPEAKER_02: Is there any mucus or fat in their stool?
• 14:46
  SPEAKER_02: Are they constipated?
• 14:47
  SPEAKER_02: Is it diarrhea?
• 14:48
  SPEAKER_02: Is it liquid stool?
• 14:49
  SPEAKER_02: You know, what's the frequency?
• 14:51
  SPEAKER_02: Do they have gas?
• 14:52
  SPEAKER_02: Do they have bloating?
• 14:53
  SPEAKER_02: Do they have GI pain?
• 14:54
  SPEAKER_02: So, you know, that's a big factor here, as is also what their diet looks like.
• 14:59
  SPEAKER_02: So if somebody's eating, and it does happen, some people will do like a carnivore diet, which is basically, if if if your listeners are not aware, is a diet completely devoid of fiber.
• 15:13
  SPEAKER_02: So it is only meat products and any products derived from animals.
• 15:18
  SPEAKER_02: And some people, now, this is sort of an oddball thing.
• 15:22
  SPEAKER_02: Like clinically, we have to go, all right, well, why does it work for some and it doesn't work for others?
• 15:26
  SPEAKER_02: For some people, they do actually see improvements and others don't.
• 15:29
  SPEAKER_02: And so the only thing that we can guess at this point is that for people who have SIBO or that small intestine bacterial overgrowth, where they might also not be able to tolerate medications, or there are actual um botanical protocols that actually rival rifaxamen and um xyfaxin and whatnot in their efficacy.
• 15:51
  SPEAKER_02: But that being said, if they can't tolerate medications to bring the levels down, some people do benefit from a short course of doing carnivore.
• 16:00
  SPEAKER_02: The problem long term with it is that you can like pretty much turn your gut microbiome into a parking lot if you're on it for longer than six months, because it will significantly deplete your good gut bugs.
• 16:14
  SPEAKER_02: And then it is extremely difficult to reintroduce plant foods and a very long and slow journey.
• 16:20
  SPEAKER_02: Um, so you know, we have to be aware that people are using these diets.
• 16:25
  SPEAKER_02: But um, generally speaking, I like to look at stool testing to get a sense of whether number one, is H.
• 16:31
  SPEAKER_02: pylori present?
• 16:33
  SPEAKER_02: Or are there patterns that indicate that basically there's a lack of appropriate stomach acid?
• 16:40
  SPEAKER_02: That stomach acid, just in case someone isn't fully aware, is not just meant to break down proteins and to help with the digestive process.
• 16:48
  SPEAKER_02: It's also a chemical barrier.
• 16:49
  SPEAKER_02: So anytime you swallow something, be it from food, saliva, something you drank, um, it should be killed in the stomach acids.
• 16:57
  SPEAKER_02: So insufficient stomach acid is not just a red flag for nutrient depletions, but it also means that you're now, I like to describe it as literally leaving the front door of your house wide open and going on vacation, which no one would ever do because you come home potentially to having a bunch of unfriendly individuals.
• 17:19
  SPEAKER_01: So, what makes what makes you get that low acid?
• 17:23
  SPEAKER_02: So it can be due to a variety of factors, excessive amounts of stress, a lot of moms eating on the go constantly.
• 17:30
  SPEAKER_02: So we're not getting into that digest and rest phase of the nervous system.
• 17:36
  SPEAKER_02: But also Helicobacter pyloriate specifically has an enzyme that deactivates stomach acid.
• 17:43
  SPEAKER_02: Um, and so unfortunately, that can be one factor.
• 17:47
  SPEAKER_02: And I will also just share clinically that you don't have to have like raging heartburn and even have symptoms to have an H.
• 17:56
  SPEAKER_02: pylori overgrowth in the stomach.
• 17:58
  SPEAKER_02: About 30% of those who are positive have no symptoms at all.
• 18:02
  SPEAKER_02: And that is actually clinically relevant because, and I wanted to pull this from a talk that I did earlier this year.
• 18:08
  SPEAKER_02: H.
• 18:08
  SPEAKER_02: pylori can actually induce um specific cytokines, uh, IL8, IL6, tumor necrosis factor alpha, IL-17, IL uh 23, which many of us know a lot of the biologic drugs are used to help attenuate.
• 18:23
  SPEAKER_02: And so, like, for example, with psoriasis, they do see that it will increase issues with the IL-17, IL6, IL-23, tumor necrosis factor alpha, um, rosacea, uh uh with atopic dermatitis as well.
• 18:38
  SPEAKER_02: And actually, interestingly enough, when they see this correlation with IL-6 and IL-17 being elevated because of H.
• 18:46
  SPEAKER_02: pylori, they'll they did note a decrease in phylagrum production.
• 18:50
  SPEAKER_02: So we do know that there's a connection there, but it but as a result of the door, front door of your house being left open, um, you're you end up with gut dysbiosis.
• 19:00
  SPEAKER_02: So you start swallowing bacteria that should have died, not only from the food around you, but from your mouth.
• 19:06
  SPEAKER_02: And mouth microbiome should stay in the mouth, not be down in the GI tract.
• 19:10
  SPEAKER_02: So that's one way you can end up with SIBO.
• 19:12
  SPEAKER_02: You can also end up with LIBO or large intestine bacterial overgrowth.
• 19:16
  SPEAKER_02: You can end up with parasites and all sorts of things.
• 19:19
  SPEAKER_02: And it's also linked to nutritional deficiency, specifically iron B12, vitamin D, vitamin C, folate, and protein, because we can't break down protein sufficiently if we're missing this crucial first step.
• 19:32
  SPEAKER_00: Interesting.
• 19:33
  SPEAKER_00: One of the questions that we get asked a lot as clinicians is about probiotics.
• 19:38
  SPEAKER_00: So maybe you could cover that.
• 19:40
  SPEAKER_00: So thinking about dysbiosis and how do you recommend probiotics.
• 19:44
  SPEAKER_00: Everybody was like, okay, use probiotic.
• 19:46
  SPEAKER_00: Well, which one?
• 19:47
  SPEAKER_00: And that's a hard, it's a hard answer to give.
• 19:50
  SPEAKER_02: It is, especially if somebody does have SIBO, it can be really tricky.
• 19:54
  SPEAKER_02: You'll notice a lot of times they can't tolerate um probiotics.
• 19:57
  SPEAKER_02: Sometimes spore-based probiotics will be better tolerated, but those usually have to be onboarded slowly.
• 20:04
  SPEAKER_02: Um, so if somebody doesn't tolerate probiotics, you should send them to a GI doctor.
• 20:09
  SPEAKER_02: Okay.
• 20:10
  SPEAKER_02: Just period.
• 20:11
  SPEAKER_02: Um the other factor that has to be considered is the stool frequency.
• 20:15
  SPEAKER_02: So whether they have diarrhea or they're constipated or they have normal stool.
• 20:18
  SPEAKER_02: And the reason that I say this is that specifically uh Sacchomyces Balardi, which may be in a bunch of different probiotic formulas, it's usually how it's there to help with diarrhea and softer stools, will actually make constipation worse.
• 20:35
  SPEAKER_02: So it's not a good idea to do that.
• 20:37
  SPEAKER_02: And you have to be careful as well in those who have uh hydrodenitis apporitiva as well as um psoriasis if there's a comorbidity of IBD present and known.
• 20:49
  SPEAKER_02: Because some of those individuals actually have anti-sacchromyces cerevase titers in their blood, which you can test for.
• 20:57
  SPEAKER_02: Um, and because it's in that family, you would not want to give that individual that particular strain.
• 21:03
  SPEAKER_02: Um, but it is friendly, generally speaking, to the gut microbiome.
• 21:06
  SPEAKER_02: Now, that said, if somebody has chronic articaria, lactobacillus rhnosis GG can be a great option, but low levels of it are not really all that helpful.
• 21:15
  SPEAKER_02: Probably looking somewhere around 25 billion CFUs a day.
• 21:20
  SPEAKER_02: Um, you know, for those with you can have staph aureus in the GI tract.
• 21:25
  SPEAKER_02: It's pretty common to see atopic dermatitis.
• 21:28
  SPEAKER_02: Uh, folks will have that.
• 21:31
  SPEAKER_02: We'll have staph as well in the GI tract.
• 21:33
  SPEAKER_02: And Bacillus subtilis, there's some research showing that it can be helpful in crowding out staff in the GI tract.
• 21:41
  SPEAKER_02: So that could be a helper whether you take that on its own or you have it included in some sort of formula.
• 21:49
  SPEAKER_02: Um, and then I would also share because I do know that a lot of dermatologists use like low dose doxycycline for various issues.
• 21:58
  SPEAKER_02: But I would suggest you be Careful.
• 22:00
  SPEAKER_02: It can it can shape and shift the gut microbiome.
• 22:05
  SPEAKER_02: So, generally speaking, I think if you are on a low-dose antibiotic, I would try to get the patient to supplement with somewhere around like maybe 20 to 30 billion CFUs of a probiotic daily.
• 22:21
  SPEAKER_02: If they can do a variety of strains, that would be great, but it should be taken two to three hours away from the antibiotic to not have it cancel it out.
• 22:30
  SPEAKER_02: But like I said, if the patient comes back and says, I can't take probiotics, I they make me feel worse, I get gas bloating.
• 22:37
  SPEAKER_02: That's a red flag that there's probably something going on with the small intestine.
• 22:42
  SPEAKER_00: So send them to GI.
• 22:44
  SPEAKER_00: Correct.
• 22:45
  SPEAKER_00: Yeah, that makes total sense.
• 22:47
  SPEAKER_00: Well, that's a it is a complicated question, but that was a very good answer to a complicated question.
• 22:52
  SPEAKER_00: So you sell some supplements and you sell some probiotics on your website.
• 22:58
  SPEAKER_00: And you mentioned spore-based, but that's not something I think most dermatologists would be familiar with.
• 23:03
  SPEAKER_00: So maybe you could explain that.
• 23:05
  SPEAKER_02: Sure.
• 23:05
  SPEAKER_02: Spore-based probiotics are different.
• 23:07
  SPEAKER_02: They're not generally considered commensal uh probiotics, but they are shown.
• 23:14
  SPEAKER_02: Um, at least I've seen really great results that for some, it will help either reverse constipation or reverse diarrhea and get the stool to a better consistency.
• 23:24
  SPEAKER_02: And some research shows that they can actually help shift the microbiome by up to like about 40% in favor of the host.
• 23:34
  SPEAKER_02: So I do like to use them, but you have to onboard them slowly.
• 23:38
  SPEAKER_02: And if you do react to them, that usually is a sign that there is very significant dbiosis within the GI tract.
• 23:46
  SPEAKER_02: Um, I will also say this: I know that there is a lot of information online and a lot of things being said about using probiotics to fix dysbiosis.
• 24:00
  SPEAKER_02: I don't tend to find that probiotics are nearly as effective in doing that on their own.
• 24:08
  SPEAKER_02: Just clinically, I don't see that always be the big driver.
• 24:13
  SPEAKER_02: If someone has not improved from supplementing with probiotics, there's a variety of reasons why.
• 24:20
  SPEAKER_02: But if you have unfriendly organisms, I mean, I've had some clients who show positive for certain types of parasites, for worms and helmet infections, um, for different protozoa like blastocystis hominus.
• 24:33
  SPEAKER_02: They have Morganella species, which produces histamine within the GI tract.
• 24:37
  SPEAKER_02: You're not gonna crowd that out with probiotic.
• 24:40
  SPEAKER_02: So I think that there's I think we have to be realistic with the tools that we have available.
• 24:48
  SPEAKER_02: There's also a problem with fungal overgrowth.
• 24:51
  SPEAKER_02: Um, and you're not gonna crowd out excessive amounts of fungus, which actually grow predominantly in the small intestine, because that's where those species actually live as commensal organisms.
• 25:04
  SPEAKER_02: So we may not see it in a stool test, um, but you still need to suspect if that's potentially there because imbalances can look like overgrowth, but they can also look like undergrowth.
• 25:17
  SPEAKER_02: And there can be pathogens as well hanging out.
• 25:20
  SPEAKER_02: So it there's it's complex, which it makes it so fun.
• 25:25
  SPEAKER_02: Um, but there's a variety of things that can be done when you mix together diet, different probiotics.
• 25:31
  SPEAKER_02: Sometimes there's different herbs and things that can be helpful.
• 25:34
  SPEAKER_02: And there is absolutely a time and a place for medications because sometimes herbs don't work nearly as well as medications do.
• 25:43
  SPEAKER_02: And that's where, you know, like you have that in your toolbox, which is amazing.
• 25:49
  SPEAKER_02: And um, you have the power in that instance to potentially help somebody because we do know that excessive organisms in any regard, um, even if they're commensals, overgrowth is overgrowth.
• 26:02
  SPEAKER_00: Yeah, still a problem.
• 26:03
  SPEAKER_00: Yeah, still a problem.
• 26:05
  SPEAKER_00: So talk a little bit about elimination diets, because I know you wrote an interesting paper, which I want you to talk about as well, but how those might play in here for our patients with chronic skin diseases.
• 26:16
  SPEAKER_00: And then obviously the downside, which is what your paper talked about.
• 26:20
  SPEAKER_02: Yeah, so I can tell you that if you don't think that your patient is gonna try eliminating foods, they're probably not a little naive sticked.
• 26:31
  SPEAKER_02: Yes.
• 26:32
  SPEAKER_02: I I I want to be I'm everybody wants to eliminate gluten.
• 26:36
  SPEAKER_00: Gluten is the devil.
• 26:38
  SPEAKER_02: Well, and the problem is depending on the particular skin issue, there's this whole laundry list of like bad trigger foods that they will inevitably come across in a Facebook group or in a book.
• 26:51
  SPEAKER_02: And unfortunately, you know, I got called a fear mongerer for years.
• 26:56
  SPEAKER_02: Every single time I was like, look, I'm I in my clinic, the the person is getting to me when they're down to like five to ten foods a day.
• 27:05
  SPEAKER_02: Like they're eating.
• 27:06
  SPEAKER_02: I I'm not even joking.
• 27:08
  SPEAKER_02: I had one client, she ate one pound of ground beef, a whole bag of spinach, pomegranate seeds, Reese's peanut butter cups, and one other thing every single day.
• 27:20
  SPEAKER_02: And I was like, How did you get here?
• 27:23
  SPEAKER_02: And what she did was she started with one elimination diet she read about in an autoimmune book.
• 27:29
  SPEAKER_02: And then she took out all these other things that she read in another book.
• 27:32
  SPEAKER_02: And because, you know, this other book on this particular diet said that these were inflammatory, she took these out and they start overlapping these different elimination diets that number one, it decreases.
• 27:46
  SPEAKER_00: Ultimately, then you're not eating anything of any value.
• 27:49
  SPEAKER_02: Not only are you increasing the risk of nutrient deficiencies, but you're also decreasing nutrient diversity, which is really important to have a diverse gut microbiome.
• 28:00
  SPEAKER_02: And they develop so much food fear because of the way that these foods are positioned.
• 28:05
  SPEAKER_02: So they're toxic, inflammatory, bad.
• 28:09
  SPEAKER_02: And so as a result, they're well-meaning, they're well-intentioned, trying to do what they can to help themselves, but they end up cutting out foods that they potentially shouldn't have cut out.
• 28:23
  SPEAKER_02: And so again, I was called a fear-mongerer.
• 28:27
  SPEAKER_02: And so I happened to, um, I talked with Dr.
• 28:30
  SPEAKER_02: Raja Sivamani, and I'm like, look, I know you do research.
• 28:32
  SPEAKER_02: Would you help me see if this is really an issue or that it's just, you know, me seeing this all the time because it's my composition.
• 28:39
  SPEAKER_02: Yeah, where you're sitting, exactly.
• 28:40
  SPEAKER_02: And so we put together a research uh survey.
• 28:43
  SPEAKER_02: Uh, we ended up getting over 600 responses and we asked a variety of questions.
• 28:48
  SPEAKER_02: Um, it was specifically geared towards people who have chronic skin issues.
• 28:52
  SPEAKER_02: So it wasn't just like healthy individuals.
• 28:53
  SPEAKER_02: Healthy individuals, yeah.
• 28:55
  SPEAKER_02: And what we found was pretty significant.
• 28:57
  SPEAKER_02: So, first of all, overwhelmingly, the majority of people believe that they need to eliminate foods to improve their diagnosed skin conditions.
• 29:06
  SPEAKER_02: So that is a belief that people have already that you can poo-poo as much as you want and try to detract them from doing that or deter them.
• 29:15
  SPEAKER_02: But this is a reality that they already think this potentially.
• 29:20
  SPEAKER_02: Um, and that of those individuals that were surveyed, 70 to 83% of the people self-eliminated the foods.
• 29:29
  SPEAKER_02: So they had done this on their own.
• 29:31
  SPEAKER_02: They hadn't even gone to work with anyone like myself.
• 29:34
  SPEAKER_02: They won't did this because of what they saw on a Facebook group or they read online, on a blog, or in a book.
• 29:41
  SPEAKER_02: And so the the condition, the diagnosed condition that that where people tend to eliminate by far the most foods is atopic dermatitis.
• 29:51
  SPEAKER_02: I would think so.
• 29:52
  SPEAKER_02: By far, more so than any other skin condition.
• 29:55
  SPEAKER_02: Yeah, I'm not surprised.
• 29:56
  SPEAKER_02: And what I did find to be really shocking was that when we asked the question, did an elimination diet trigger a negative association with food?
• 30:05
  SPEAKER_02: We broke it down.
• 30:06
  SPEAKER_02: There was two, there's two different graphs on this particular um poster that was published.
• 30:12
  SPEAKER_02: So um, first we looked at age groups.
• 30:15
  SPEAKER_02: The most disturbing was that in the 18 to 24-year-old age group, over 80% of those said strongly agree or agree.
• 30:25
  SPEAKER_02: So they now have a negative association with food.
• 30:28
  SPEAKER_02: That's really alarming.
• 30:30
  SPEAKER_02: And then even when we get down to the 55 to 64 year olds, we still have 47% of people saying that they now have a negative association with food.
• 30:40
  SPEAKER_01: And what were they eliminating?
• 30:41
  SPEAKER_01: Did you tease that out?
• 30:43
  SPEAKER_01: The actually, we have a whole diagram on all the different food groups that were eliminated.
• 30:47
  SPEAKER_02: It's extensive.
• 30:49
  SPEAKER_02: Um, and then when we looked at this overlapped with eating disorders, this is where you have to be really careful, especially if you're well meaning, you're like, oh, try this diet.
• 30:57
  SPEAKER_02: It you have to ask the patient if they have a history of eating disorders, because over 60% of those surveyed with a history of an eating disorder said that the elimination diet triggered a negative association with food.
• 31:14
  SPEAKER_02: But even over 54% of those without a history said they now have this negative association with food.
• 31:21
  SPEAKER_02: And what happens is people get really afraid and they don't reintroduce.
• 31:27
  SPEAKER_02: And then what is worse is, and this is something we're seeing clinically, we're not as uh sure as to why, because I've talked to colleagues, for those who have eliminated these foods for around a year or more.
• 31:40
  SPEAKER_02: And when I say eliminated, like strictly eliminated, we're now starting to see people when they try to reintroduce, especially the top nine allergens, develop an IgE anaphylactic response.
• 31:53
  SPEAKER_02: I have two clients now who have to have epi pens, one to dairy, all dairy, and then the other to eggs.
• 31:59
  SPEAKER_02: And they never had an allergic reaction, but they were told that these foods were inflammatory and bad, and read about them online and took them out and now have an allergy.
• 32:11
  SPEAKER_02: So we need to be careful.
• 32:13
  SPEAKER_01: Um serious.
• 32:14
  SPEAKER_02: I'm really curious, like about Dr.
• 32:16
  SPEAKER_02: Anne Marie Singh.
• 32:17
  SPEAKER_02: She's an allergist and some of her research looking at this.
• 32:20
  SPEAKER_02: Um, we're not entirely sure why.
• 32:23
  SPEAKER_02: I've talked to Dr.
• 32:24
  SPEAKER_02: Leo about it as well.
• 32:26
  SPEAKER_02: Um, so I just want to caution how we discuss food and to let you know too that if you're not comfortable having these conversations, the two qualified, um the two qualified types of individuals who are allowed and who are trained to have these conversations are registered dietitians and uh certified nutrition specialists.
• 32:47
  SPEAKER_02: We are the two scopes of practice that are able to work with people around their diet, whether eliminations are appropriate or not.
• 32:54
  SPEAKER_02: We can do a lot of different things because we have the appropriate training to do this.
• 32:58
  SPEAKER_02: Um, but I just don't want to see somebody end up in, you know, in this horrible situation making everything worse because they were well intentioned, but they just didn't have the right guidance.
• 33:10
  SPEAKER_00: Right.
• 33:11
  SPEAKER_00: That's a fascinating study.
• 33:13
  SPEAKER_00: I you sent it to me.
• 33:14
  SPEAKER_00: I will read it more thoroughly.
• 33:15
  SPEAKER_00: But I thought it was really interesting.
• 33:18
  SPEAKER_00: So we're a little over time, but I do want to ask you quickly about your skincare and what types of things you have in your skincare products on the Quell website.
• 33:28
  SPEAKER_02: Yeah, absolutely.
• 33:29
  SPEAKER_02: Um, so we have three creams, and one is a moisturizer that you can use daily.
• 33:35
  SPEAKER_02: I use it as a night cream on my face.
• 33:37
  SPEAKER_02: I I love it.
• 33:38
  SPEAKER_02: And then we have uh one product that is called the Nourish Butter, which is predominantly hemp.
• 33:45
  SPEAKER_02: I saw that.
• 33:45
  SPEAKER_02: Yeah, it's a it's a hemp, uh hemp seed.
• 33:50
  SPEAKER_02: Um and then we also have one called the Z Plus Rebuilder, and that's specifically because it has zinc added to it, but we've also added other beautiful um ingredients, like for example, in like St.
• 34:01
  SPEAKER_02: John's wart, topically can cause this sun sensitization, but because it was infused into oils, it no longer carries that.
• 34:10
  SPEAKER_02: And so it just has more of the nourishing properties to it.
• 34:13
  SPEAKER_02: So we did a lot of fun things in infusing the oils as a way to get away from essential oils in the products.
• 34:20
  SPEAKER_01: Yeah.
• 34:21
  SPEAKER_02: Um, and we have things like carrot seed oil and um there's calendula and all sorts of things.
• 34:27
  SPEAKER_02: So I just really, you know, I wanted to bring something to my community that I thought would be helpful and useful.
• 34:34
  SPEAKER_02: And we actually now just launched a bath soak.
• 34:37
  SPEAKER_02: So I'm excited about that.
• 34:39
  SPEAKER_02: And uh interesting.
• 34:41
  SPEAKER_00: Yeah.
• 34:41
  SPEAKER_02: So where is your practice in Chicago?
• 34:43
  SPEAKER_02: No, I'm located outside of Philadelphia, and we see clients virtually.
• 34:49
  SPEAKER_00: Oh, nice.
• 34:50
  SPEAKER_00: So anybody can access you.
• 34:52
  SPEAKER_00: Fantastic.
• 34:53
  SPEAKER_00: This has been so incredible.
• 34:55
  SPEAKER_00: I can't tell you.
• 34:56
  SPEAKER_00: I learned so much.
• 34:57
  SPEAKER_00: I know everybody out there is listening, has learned a lot.
• 35:00
  SPEAKER_00: And thank you so much for sharing your expertise with the community, the science of skincare community.
• 35:06
  SPEAKER_00: And hopefully I'm gonna circle back to you about that, and maybe we can find an interesting topic for you that you would be gracious enough to share your expertise with our audience as well.
• 35:17
  SPEAKER_02: That sounds wonderful.
• 35:18
  SPEAKER_02: Thank you so much for having me.
• 35:20
  SPEAKER_00: Great, thanks so much.
• 35:21
  SPEAKER_00: And everybody remember Science of Skin Care Summit, November the 8th through the 10th, 2024, in Austin, Texas.
• 35:29
  SPEAKER_00: Bye bye.