#103 Integrative Dermatology for Eczema with Dr. Peter Lio

Know anyone with eczema? 

Dr. Peter Lio, the founding director of the Chicago Integrative Eczema Center and a Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University joins us in this week's episode of the Less Stressed Life Podcast to broaden our knowledge on eczema and skin rashes. 

Key Takeaways:

• [05:08] What is eczema?
• [15:33] Effects of staph bacteria on skin, sleep, and behavior
• [18:26] What is Transepidermal Water Loss?
• [20:07] Relationship between food and eczema

Mentioned in this episode:

• Aron Regimen by Dr. Richard Aron 
• Gladskin by Micreos
• The Pink Magic B12 Cream by Dr. Peter Lio 

Dr. Lio attended Harvard Medical School and stayed on for dermatology residency at Harvard, where he was Chief Resident.

Dr. Lio is committed to providing the highest level of care to patients of all ages. His special interests include pediatric dermatology, eczema, acne, dermatomyositis, and other inflammatory diseases of the skin, and he works to integrate alternative and complementary medicines in dermatology.

Today marks the kick-off of SKIN-month and I'm happy to share with you my book The Eczema Relief Diet & Cookbook coming out next month (April 14th is the official ship date) but it's available for pre-order on Amazon. 

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Transcript

spk_0:   0:00
we have the microbiome on our body with all this bacteria and fungus and viruses. Okay, so this huge group of organisms living on our skin and inside of our body and those guys have differential constituents in different parts of the body. So we know if you take a little culture or do the genetic testing of the microbiome in your armpit, it is totally different than what's going on in your foot.

spk_1:   0:20
Welcome to the less stressed Life podcast, where our only priority is providing those ah ha moments toe up level your life, health and happiness. Your host Integrative Dietitian nutritionist Krista Bigler, helps health conscious women reduce the stress and confusion around food, fatigue, digestive and skin issues at less stress. Nutrition dot com Now onto the show today marks the kickoff of Skin Month on the Less Stress Life Podcast. This is in celebration of the book I have coming out next month. April 14th is the official ship date, but it is available for preorder on Amazon. I'll put the link in the show notes. It's called the Exam a Relief diet and cookbook. Short term meal plans to identify triggers and soothe flares We've got an awesome lineup for you that I think is relevant to everyone because everyone has skin. First up, we have integrated dermatologist Dr Peter Leo, and later in the month we have integrative dermatologist Dr Rogers Siva Mani from California. We also have my colleague Jennifer Carron brand talking about examine in little kiddos, and Chris Master John, the Micronutrient guru. Talking about nutrients for skin should be a great month. Let's get started. So I have with me today on the less stress life Dr Peter Leo. And if you don't know him yet, I'm sure you will be tuning into whatever he's got in the future. He is the founding director of the Chicago Integrative Exam, a center and clinical assistant professor of dermatology and pediatrics for Northwestern University. He attended Harvard Medical School and stayed on as a dermatology resident at Harvard, where he was chief resident. So Dr Leo is kind of I think, he's kind of well known as speaking concisely but intelligently about integrative dermatology. And he's here to share some great incentive us today. Welcome, Dr Leo. Thank

spk_0:   2:03
you so much for having me. It's a pleasure to be here.

spk_1:   2:05
Yeah, s. So how is it person getting to integrate of dermatology? Because this is a big topic. Big area, right? We're going to talk a lot about exam today, but of course, so many other skin conditions and I often hear I work with a lot of kids challenging group as you did, and a lot of people see, How do you even find a degree of dermatologist? And so how did that happen for you?

spk_0:   2:23
Yeah. I mean, I think right now it is really hard to become an integrated dermatologist because there's no way that we really have set up. There's on a pathway that's been clearly defined, and I kind of feel like we're trailblazing it a little bit and trying to build it. I think you know my good friend Dr Rogers of Amani. He and I have been working on putting together more of a formal curriculum and almost like flirting with the idea of building a fellowship of sorts for people who are interested. But for me, it happened kind of organically. I've always been interested in alternative approaches. I've been interested in energy medicine in traditional Chinese medicine and during medical school. Actually spent some time working with Ted, Cap Chuck and David Eisenberg, who were both kind of real pioneers of this area and learning about alternative medicine. And then when I I did my residency, I sort of became the person that they would say, Well, he's interested in this stuff on to talk to him about it, wanted to see if he knows anything about this. And little by little, I became known as that. And then I decided to make it a little more formal. So I spent a full year studying medical acupuncture, which was fantastic, and then a second year, still practicing and kind of apprenticing and learning more about it. And that really was eye opening in really grounding to get deep into a different tradition. And from there it's just been kind of going and learning as I go. It's been exciting,

spk_1:   3:29
cool. I feel like I've known a lot of doctors who've gotten into medical acupuncture. Was that something that you saw results from in your dermatology practice while you were kind of practicing and studying with it? Because it's not something I see or necessarily hear a lot of my clients.

spk_0:   3:42
Yeah, I definitely do see some results, and I think it's a very powerful modality. One of the things I love about acupuncture is that it's doing a lot of things at once for the patients, So it's like a great adjunctive treatment for a lot of things. I don't know if it's strong enough by itself. You know, in the dorm world, like for certainly for pain, for back pain and muscle pain and muscle injuries. It's fantastic, but for damn stuff, A lot of times is not quite enough to do by itself, but as an adjunctive or an additional therapy, it's really good. It just sort of strengthens the body, helps things work better, helps with it, helps with anything stress related to because I feel like it's we have kind of harmonizing the body again.

spk_1:   4:14
Cool, great. So even though there's a lot of skin conditions, we're gonna focus on exam a little bit. Today, which is pretty widespread, affects a lot of people, and the challenges are when you're digging into the research, it's like do this, but not too much or do this, but not too much. There's a lot of contradictions when I'm in the research. The nice thing about you and your colleague Dr Silverman E are doing is that you are trailblazing and you're doing a lot of research, which we appreciate because we always need more research. So let's first talk about what is eggs Emma. Yeah, what are some of the limitations around? Essentially, my question is it's all very different, like we have one name and there's lots of types, right?

spk_0:   4:46
Exactly. I think that right there is the deepest point, maybe of our whole time together here, because to understand that, I think, really explains so many pieces. It's like because it's not one thing. And that's why there's so many different approaches in so many different causes and what some people say. I just cut gluten and I'm totally clear. And then I have other families are, like, totally cook gluten for six months and it hasn't helped. Why not? You know, everyone said that was gonna be the secret, because it's probably not one thing, but Exuma is a set of conditions that are defined by being itchy rashes on the skin. They have to be a G. They have to be recurrent or constants of some poor people literally have no clear days, but most people have ups and downs, but it has to be chronic and intimate. You can't just be a one time or a couple times thing, and the other key piece, Texoma, is that it has a characteristic appearance and distributions, So there are other rashes that are itchy and chronic. But to be examine, it has to have that look in that distribution, and that's aged related as well. So once you have those three things, you're in that group of exam A. And then there's lots and lots of different types, so atopic dermatitis is sort of the most precise version that we have. And then what kind of call it that when we're doing a scientific study or search piece? But Exit was a little broader than that. Will include things that are close to its own, uh, Mueller dermatitis follicular type exam? A. Some people actually have non a topic topic dermatitis. Some people call that a top of form dermatitis, where they don't have any other allergies. They have no high I g level. They don't get hives, they don't have foods. Driving it now it's controversial are they the same of the different Do they call them a totally different name? We don't know. And then things in the exam a group even are things like separate dermatitis, contact dermatitis. All those things can also look like it have similar features, but have different ways to approach in different underlying ideologies.

spk_1:   6:21
Cool. So when I think about skin stuff, I almost have to segment Let's talk about it from the outside. And then let's talk about it from the inside. So let me talk about from the outside first, because this is where I don't know if you want to talk about this, you know, you listen to your kinds really closely. I listen, mind really closely, I pay attention to where the exam is presenting to. Do you think that there is a relationship with where the exhibit presents on the body and you know, one example. I'm gonna bring this up because you said you study you were interested in Chinese medicine, for example, Chinese face mapping, which I've I had a hard time finding like a perfect reference for But I just paid a little bit of attention, like hey, according to ancient Chinese medicine, which was usually right about everything before. We usually rediscover it later. You know, there are some associations with this part of the body and that So my general question is, what do you think about presentations on where it occurs in the same part of the body? Is there anything to be said about that?

spk_0:   7:08
Yeah. No, I think you're right. I think it can have a couple of different meanings for sure. But I think there's meaning in all of it. A lot of it is just sort of beyond us, right? I think one day hopefully will say, Oh my gosh, now we totally understand why it was year. So, for example, like I'm babies if you notice most of the babies have really bad exam on their cheeks, but the nose is usually spared, right? Some people call that the headlights sign that's been coopted well as well. In the topical story withdrawal community, they have a similar thing. They call the headlights time, but it was described, you know, in the fifties has being a sparing of the nose, and we didn't know why, but it turns out that natural moisturizing fact is actually has a differential maturation rate in different parts of the face. There was a beautiful paper mapping this, and I was like, Oh my gosh, you just answered a very, very old question because it turns out the nose matures really quickly within the first few weeks or month of life, whereas the cheeks take many, many months or even years to have full maturity. So the skin barrier is in many patients, much, much weaker. And the cheeks of what we're seeing is the kind of Latin term for it. The locus Mannerist residential, right? The point of least resistance. That's where the weaknesses and that's where you see a breakout so that the one example of what that means another example might be things in allergic contact dermatitis. If things were touching the skin, it rubbing the skin or exposes something, we'll totally see it happening the same place. So, for example, many of my patients become sensitized to nickel right nickel metal. Why, it's so weird. But these are very widespread allergy, so we'll look on their belly and right where their belt buckles Fitz or in jeans. You know genes have metal backing. You'll have a bright red dot, and when you see it, you know, like I think you're allergic to metal. In some patients, like you're right, this makes perfect sense. No wonder other patients like I don't think you're right. That can't be That's crazy and all. But could you just do me a favor and put if he's a duct tape on that? And they come back a month later and like, Oh my gosh, I cannot believe this, you know, that's really what that waas So there are those kinds of things, and then you're right. They're also probably our internal connections, like things happening inside the body that are bringing it out in certain areas because we now know there's a whole additional layer even that Chinese medicine didn't really explicitly No. I think they in a way they accounted for because there's so much wisdom there. But I don't think they really knew about it so overtly. But the concept of microbiome right? We have the microbiome on our body with all this bacteria and fungus and viruses. Okay, so this huge group of organisms living on our skin and inside of our body and those guys have differential constituents in different parts of the body. So we know if you take a little culture or do the genetic testing of the microbiome in your armpit. It is totally different than what's going on in your foot. So what they're doing and they're very sensitive to change and disruption. They affect Exam A. Hugely, and we can see these shifts happening there, too. So inside the body outside the body, the microbiome, which is a big part of our body, that's sort of been invisible and probably other things I don't even know about yet.

spk_1:   9:40
Yeah, I'm gonna dive into that microbiome piece here shortly. But let me ask you a question On behalf of some clients. I don't have the answer to this, and you may not either. I think there's some stuff out there that says, Hey, if you've got exams presenting on your trunk, it's different than when it's presenting on your outer lambs because, hey, it's getting closer the organs, because someone said that to me recently. Isn't it better that it's moving farther away? And I said, I don't think we know that for sure. Give any opinions?

spk_0:   10:04
Yeah, I don't think so. you know, I think from the skins perspective, I think this closeness to organs probably is not so much in its set up. You know what I mean? Like it. I think we're seeing that from a three d standpoint. But I think from the skin standpoint, each different area is different. So my sense is probably know a lot of my patients are really severe and they're pretty much covered. So I see that a lot. And then we do know there are these age specific patterns. So many adults have severe severe hand dermatitis but also have had a neck involvement. But some of them also have trunk of moments of my gas is they're probably something to it, but maybe not quite. That line of reasoning is my guest, but who

spk_1:   10:36
knows? I don't like I really know for sure. Yeah, you mentioned head. And in my research there's often type of fungus. It's overgrown on ahead. So do you see? I mean, we see this like starting cradle cap, which we don't call Exuma, but it's a derm condition, right? So do you see that? That is a like a do over culture for fungus topic Lee. Where do you find that? Like how often is that an issue?

spk_0:   10:54
No, it's a great point. So yes, So malice. Easy A is the yeast that over grows in Some patients, at least with this, had a neck dermatitis pattern, and it is indeed similar to, or the same one that is causing some break dermatitis and babies, which, you know, I do classify as an exam odds and that family. So it is not a topic dermatitis, of course, but it is an eczema. And, you know, for babies, it's usually malice. Easiest, Um, podia Alice Normalcy is equal. Both. So so. There's different sub species. It turns out there really, really hard to culture. Regular culture thing that we're doing Clinic will not grow them, so you'll get a false negative, unfortunately. So if you just swab it and say, Let's see, you know like you would for tenure. It will not unfortunately grow and requires very specialized growth conditions. And that's one of the hard part that we've learned had the hard way about the microbiome because we've done just these very crude cultures. But it turns out in that what happens in the culture medium is the big guys fight each other, and you might see one or two strains, you know. But there's actually a whole harmony that's happening in the whole global community, on the skin that's there. So we've had to do better. Better tools to figure that out. But absolutely, that's a problem. Now the question here becomes one of chicken and egg. Is this just like a pathogenic bacteria or yeasts that's causing trouble? Or is there some underlying deficiency that is allowing this normal commence? A. Which it is because of all of our skin, has some Allis easier on it. But in this situation to be over growing. So is it that there's some underlying deficiency or overproduction of some fat, something that makes it go crazy. And so you get stuck in these chicken and eggs a lot, So if you just like well, let's just nuke this yeast, you know, it's like okay, but if we don't fix the underlying problem, then you've just knew these temporarily and might bounce right back. Alternatively, you know, sometimes fixing the skin or strengthen the skin can make the bacteria or yeast that's going crazy disappear. So you know. I mean, it's all in that that very complex interplay in balance, which I think is amazing. What keeps me so excited about it? Because it's complicated, but yes, absolutely. The yeast overgrowth is a big problem, and for certain people, we do blast the East quite literally, and that seems to make a huge difference.

spk_1:   12:42
Yeah, and on that note, you had said, it's hard to get this to culture if you just go into your doctor and say, Hey, can we just swab this area in my head? I've experienced that with clients. It comes back negative, and then, apparently you use different types of fungal medications. I'm a huge fan of frantic jungles, if necessary, and use different ones for different types of fungus. But depending on what someone goes on, sometimes they improved dramatically. And so, despite a negative culture, I'm like, What is that? You just that teaches that there must be some physical component. Typically, that's

spk_0:   13:07
a great point. You're right, and certainly that's how something's air discovered, right? It's like we couldn't see it, but it sure responded, and actually there's a fancy name for that concept, which I love, and that's called a diagnosis X. You've antipas, and it literally just means you made the diagnosis by what helped write. So use an antibiotic and it helped them. So boy, it sure seems like the bacteria was overdoing using anti fungal and help temperature Seems now the only little trick here is that so many of our medicines there, actually Swiss Army knives, that they don't just do one thing. And there are very few things that are pure. And so that's one of the little pitfalls where it's like, Gosh, you think this is anti bacterial, you know, So this must be a bacteria, but for example, in rows, Atia turns out that we use a lot of antibiotics for it. But in recent years, we've really been able to find that you can use such a low dose that it doesn't actually hurt any bacteria. And it turns out that antibiotics are really anti inflammatory, too. So there are these weird little secondary things, and that's true of a lot of anti fungal agents. They have some effect on our own immune system, which makes things even trickier, right?

spk_1:   14:02
Totally tell us what that Latin word was again.

spk_0:   14:04
Diagnosis X. You've Antabuse diagnosis extra antipas, and it's making a diagnosis by trying something empirically and seeing that it helps, which is really kind of neat, right?

spk_1:   14:13
Cool. I do like you know. The other thing is we talk about about the microbiome inside and outside of our body. I think people talk about fungus or were they quote unquote candida and people elected? But there's an entire maiko bio or the fungal ecosystem, and I think that's something that we haven't really tapped into, or we don't talk about as much as the microbiome. Or maybe we just kind of bundle them together. But they are a little different. I think we just don't understand our fungal ecosystem as well as we maybe could.

spk_0:   14:37
Oh, I 100% agree. I think your story, and what we're hearing now is people are just starting to understand this microbiome part and the viral bio right? There's a whole viral piece, too, that's doing their whole thing. There's these bacteria if ages, and they're all doing their peace. So it's it's amazing. It's so much more complicated, and it's one of those things. The more we learn that we're like, Oh, my gosh, there's even more like it just keeps going and

spk_1:   14:56
going. Yeah, and to be clear, although most people listening to this are well aware. But what? You're taking it as an antibiotic. That's for bacteria and anti fungal zehr different and antivirals are different. So even though the meds or Swiss army knives, sometimes if we're doing one thing and it's not working, it can be a different ecosystem. Essentially. So what's really common with eggs? Emma is topical staff. We see that everywhere, right in the research, like topical staff, topical staff, topical staff. So, personally, I see a lot of internal over ground staff and strip. What do you see? I've heard that, like maybe people I don't think we unanimously agree on this. And I think we're looking at it in different ways. So tell me how you feel about this.

spk_0:   15:33
Yeah, I mean, we think that there's definitely a staff in balance in a lot of these patients, and you're right. I mean, it's definitely receding around the skin a lot, but it's probably internally imbalanced you because we know the skin in the gutter intimately connected. So what's going on in the skin tends to be reflecting what's going on in the gut, so I don't think that's weird at all to see it internally as well. The thing about the skin that we've learned and this is still kind of controversial. We're right at the cutting edge because if you were talking to a different dermatologist, they might say, Well, this is kind of what we had learned when I was a medical school with that staff is more of just a opportunist. So when there's broken skin from Exuma than the staff just likes to take up residence there and hang out, and that's kind of how we learned it. And sometimes it can cause an infection. And then you could treat that. That's the only time you should treat. Otherwise, it's just a colonizer, just basically being a punk but not causing direct trouble. And now I'm convinced and many other people are convinced. But still, I would say not everybody. That staff is actually a major driver of a topic dermatitis in many patients, and that that staff is not just a colonizer, not just a bystander, but it is actually driving it Now we have some mechanisms to because we know one of the things that it does. It makes a number of toxins. So these endo toxins that it produces, like delta toxin. You can actually show in an animal model that if you take this toxin, this protein based toxin putting on the skin, you actually cause skin breakdown to damage. So this is, like, amazing. And this is really, really turned everything on its head just in the past few years, you know? And I think again everyone's slowly kind of realizing this is the real deal. And then there really does bring up that same question. What kind of alluded to at the beginning, though? Is it the staff coming, you know, from totally external that's driving all this? Or are their host weaknesses that are allowing it? And like most controversial truths, the answer is probably somewhere in the middle. There sort of has to be a host efficiency of skin breakdown, some problem with the immune system in terms of fighting it. And then we have this opportunistic bacteria that becomes not so opportunistic anymore and now is actually becoming a conductor and influencing the scan. So you get stuck in these cycles, and that's very much. How have you A top dermatitis exam is a disease of cycling. You get trapped where the skin is inflamed, the bacteria is out of order. The immune system is going crazy to try to balance all this. Meanwhile, the skin barrier is caught in the crossfire, ripping, you know, getting ripped apart, getting broken down toxins, literally scratching and rubbing, ripping the skin apart. And then we have all the behavioral pieces. Now this is all affecting behavior and sleep, and we know how important sleep is. So now you have people getting crummy sleep. They're totally stressed out. Their skin is falling apart, their immune systems exploding. It's like, Oh my gosh, how do we get you out of this, right? This is a bad.

spk_1:   17:56
Totally. I tell people I told my skin clients all the time. I'd way rather deal with just a digestive condition because at least is not inside outside and all over. And let's go back to outside. Right now, we are in a change of seasons, and sometimes skin changes with the weather. Now, when you're reading dermatology research, it's all about T W l right

spk_0:   18:15
trends. Trans epidermal water lost.

spk_1:   18:18
So is that what we're looking at with weather when the weather becomes dry and we're losing him it in the air? Is it affecting water loss through the skin? Or is it something else?

spk_0:   18:26
Yeah, it shouldn't be. You know, a normal, healthy skin should have a pretty constant trans epidural water loss. It does change throughout the day and changes throughout different stuff that's happening. But if your skin is healthy, it keeps that water lost down. When the skin barrier is damaged, then the transit of water glass goes up. So that's really an indicator of skin barrier damage or dysfunction during the winter. One of the things that happens just that our stratum corny, um, hydration goes down. So as there's less humidity, that's relative. And, of course, as the air is just cold and changing on us, I think it's just hard on the skin and starts to Chapin chaff, and that then leads to the loss of water in the stratum. Corny, um, and then, if there's any even little tendency tohave the barrier problem, that's when you start seeing the barrier get leaky and you get trans epidermal water loss increase.

spk_1:   19:09
Actually, let's talk about leaky skin because that is sort of like a Dr Peter Leo term that he loves,

spk_0:   19:14
right? Yes, that's one of my favorite made up terms, coz you know, really, I learned about it from the alternative community in terms of leaky gut right, which is often made fun off. And when I talk about it, a more conventional group, I have to be really careful. And I introduced them to it slowly because many people like it's a bunch of Woo woo. Come on. And I'm like, No, no, no, no. This is very, really like, This is an actual thing. You can actually show it with. Sugar is we can unite to go through some of the science And then everyone's kind of like, Really? Yes, really. But it's very much like what we see on the skin. So I like to call a leaky skin and, like you got those two Ron hand in hand.

spk_1:   19:46
Yeah, totally. Okay, so let's talk about another thing that I hear about a lot, which is food and exam A. How many people come into your office when want to know if food and exam are related or how they're related,

spk_0:   20:02
I'd say all, I think, pretty much 100%.

spk_1:   20:05
So what is the relationship there?

spk_0:   20:07
It is really, really interesting to me and really complicated to me. And probably the truth is that is not one answer, right? So for some people, I really think there is a group of people and man, are they lucky where they can find a food or foods that, if not truly trigger them, But they make them more susceptible or make everything worse. And they can remove those foods and their golden. Those guys are lucky ducks. They are patients who almost never make it to me. But they are very busy, are telling everybody on the Internet about their success, which makes me a little sad because you'd be a little bit like, Hey, my taxes weren't you bad this year. You know, I'm so happy. I'm gonna go buy something nice and in your port neighbor who got crushed. Her taxes kind of feel like that. I do something wrong, you know? How come my taxes were so high? So it's a little funny when we think about it, because I wish that were the answer for everybody. That's one group. There is probably a middle group that I really think is interesting where I think that bad diet. I think there are foods that are pro inflammatory that are not good for them, that there's a whole part of this larger holistic health piece that is just gonna whack. And if they get stuff better and they cut out some of the bad foods and just eat generally healthier, I think they do better, too. So that's kind of the middle group. And then there's kind of the most extreme group that I unfortunately get a lot of, because by the time they make it to me on a referral centre, only if I'm usually seeing patients that have seen a few other practitioners, they come in and usually it begins there crying because they feel incredibly guilty, incredibly ineffective. It's usually the mom, you know, for better or for worse. It's the moms to carry the guilt and they're sobbing and they're like, You know, we saw a really great naturopath or we saw a great dietitian or we saw a great holistic doctor or even, you know, pediatrician, conventional doctor, he said. we think this is food. And we did gazillions of dollars of testing, some of which was conventional and covered, some of which we paid, you know, four or $500 to Dogg testing and all this definitely identified all these things, and we tried it, you know, we tried it for a number of months and honestly, typically, what will say is this you got a little better. It seemed like he was getting better, Really did. And then things fell apart and we tried longer. And then we saw the practitioner again. And the LA Times will say, Well, you just gotta hold it up longer. Six months isn't long enough, you know. And then the mom starts falling apart and the kid starts falling apart and everyone's falling apart. And so it's a real hard moment. And what I often will say that that plan is I'm like, Please don't blame yourself. I'm like, Is it possible that if you did this forever, maybe, you know at some point it would work? Yeah, it's possible eyes, you know, scientifically, you can't prove a negative, you know? Is it can I say 100% of the time that you know 100 stand surety. That purple truck with you know, yellow stripes will never pass in front of my office. No, you'd have to wait forever to say never. So I can never know. But I think that the risk benefits are now flipped. Now, to put the stress on you to try to do all this avoidance, you're failing it. Meanwhile, the kids miserable and covered in examine, covered in staff and, you know, totally falling apart. It's like I don't think this is the right path anymore for this group of people. And despite all that, despite the fact that come to me, you know, and all this stuff sometimes they're saying no, we still want to keep trying. And that's a real hard moment for me. So I've seen that. You know, I'm an old man now. I've been doing this for a long time. So many, many, many hundreds of patients, if not thousands now, because I focused on exhibit and that's a hard moment, you know,

spk_1:   23:06
it is on. You said somebody important things there. Couple things that I wanna pull out. Everyone used a good diet, right? But you don't need to be on food jail, and if you're in food jail, then you're creating more stress, which I would love to talk about. Cortisol, to

spk_0:   23:17
love, that love that term to food, jail, that's

spk_1:   23:20
food. Jail is like not okay, and I get a lot of people at that point to. But I find a lot of reward and like getting out of jail with people because, really, what's driving the food issue like maybe it was a little bit of a food issue, So it's good to have. I always use a sprained ankle analogy where you know, if we sit on the couch for a little bit, that can be like just reducing some of the inflammation that we may be triggering by what's going on our mouth, whatever that is. But it's not like you don't just, like, sit on a couch when you have a broken ankle and it's like perfect. That's not typically an answer, so you need to let cast it and do it some other modalities and then be able to get up in, like resume life and not be sitting on the couch. And I feel like that's the simplest way to talk about it. Where people Oh, I see that now. Okay, that makes sense. So you said something else that I think is really important, that I have learned through practices. Well, there's no amount of food changes that if you have topical and this crazy staph infection, it will not fix that. Like you have to address that staph infection because if it is really angry, like you can very clearly see it, I'm sure that walks in your office and you can just see it right when that's going on, like I feel like that's priority. You have to fix that first because when that's angry, like nothing's gonna improve.

spk_0:   24:22
Totally. Thank you, thank you. And I love the couch analogy with the broken foot or broken ankle. I love that.

spk_1:   24:27
Yeah, cool, Good. And actually, as you were talking, you mentioned a couple things about testing and type said, whatever. Haven't episode about that. I think it's 23. You don't do any food testing before you listen to this just so people understand, like it's not a fit for everyone, but sometimes just like a good tool. But it's inappropriate to say we're gonna limit this stuff forever and ever and ever. I mean, there are some outliers there, but it's not super appropriate cause, like we're here to enjoy life and enjoy our time. So we talked a little bit about topical staff there. So let's talk about something that's being used a lot now for capital staff and inflammation, which is a compound ID treatment of a lotion with a libertine antibiotic. Will you tell us a little bit about that? And how you just gonna practice?

spk_0:   25:02
Sure. So about six years ago now I had a patient who was pretty severe, had been on lots of lots of heavy duty stuff who called me and said, We heard about this guy, Dr Richard Aaron, who's originally a South African dermatologist. He was practicing in London. You practice most of his career in London, and he came up with this concept that if you mix a little bit of story and a little bit of new Pearson in the UK and in South Africa, they use Hasidic acid like another top of plant, a picture which we don't have here in the States. But it's a close cousin in the way of me. Pearson and put it in a moisturizer base. And you put it on, you know, 3 to 6 times a day it works. And when she told me this, I'm like, Well, that's just sounds silly, you know? I mean, come on, that's super diluted. Unlike you have all this stuff in your house, you know, like literally, they had made a method zone. They had the appearance. And I'm like, you have it and just like, can we just try it? And I said, Sure, I'm like, Absolutely. If this do you want time, we could try. It's not gonna hurt you, you know. It's very diluted. So go for it. So I called in the prescription of compounding pharmacy. They made it. You know, it's not super senses, not super cheap either. I think they paid you mostly pay, like 80 and 100 and 20 depending on sort of how we make it and how much we've given that you were

spk_1:   26:01
the night of

spk_0:   26:02
sleep. Oh, definitely worth a nicely brain. That and for many people, that can be, you know, 34 weeks of medicine in the beginning and sometimes many months, once they're better. You know, they're using a lot less. So it's you're right. It's a great way to put it. So I kind of forgot about it in a week later, the mom called me and the mom was sobbing into the phone so much so that she couldn't. You know, when you're crying so hard, you can't talk. She was just sobbing, and I had this terrible feeling that, like I really thought the patient had died. I really did like, what's the matter, what's going on? That she finally caught her breath and she said, It's the best thing you ever gave us. It was like completely caught off guard, like Wait, what? What are we talking about? And I had to go back to the note or Mike. Only thing in this. I said, This is incredible. I like she's She's OK, so she's not only OK, she's the best she's been in years. She's back and she's running around. She's so happy. I'm like, Oh my gosh! So the next day I get a call from another family that I run the support group and these guys knew each other from the support group and they talk and they said we want to try it and I have to be honest. I gave the same spiel. I said I don't think it's gonna help. It's really deluded. You have all this medicine like you've been on all these powerful things. But I'm like, Go for it and I kid you not. And this is when I knew there was something, we run something. They called me a week later and said, This stuff is amazing. So then I said, OK, OK, there were on to something here, you know, this Israel and I started recommending it to people and then I kind of did it right up. I didn't read it. I think about 116 patients, kids and adults that had tried it. And we split it into groups of people that had been on essentially like a mid potency story or above like to kind of prove that it was helping people that kids, you know, when I tell it to my colleagues like Whoa, what over there? Just using something they weren't even using anything I'd like better than and I'd like to say the's air. My patients, like we've been doing lots of stuff we have regimens, we write stuff out. We've been like I'm telling you, you know, and it's still it's still very controversial. When I speak about it, there's a lot of pushback, but I'm quite convinced that it is an incredible, incredible therapeutic approach that has helped tons of my patients. And I can legitimately say people that I thought we're gonna need a systemic agents. Some of them actually turn around on the air in Regime, and since then I've gotten to know Dr Erin. I got to go down to Cape Town, South Africa, and hang out with him and do some lectures there, and it was just stunning. And he's a wonderful, wonderful, dedicated guy, and that helped me to once I met him or Mike. Oh, he's not making anything off this. He's not a show. He's not a Charlotte, and this guy is truly dedicated. He cares so much about his patients, is 80 years old, by the way. He just turned 80 and he's getting ready to kind of wind down. But he's just the most wonderful guy, so I'm a huge fan of it. I really think he is someone who has contributed to the field and push things forward. And I think I can take that away from him, even if maybe this won't always be used. Maybe someone also modified or finds a better approach. Because, you know, one of the things people don't like is they don't want to put in your peers and out into the environment too much because it might make resistance. There are some issues, but I still think I give him all the credit for this incredible innovation.

spk_1:   28:34
Yeah, I think I felt similarly first. I was like, No, I don't think, you know, because for whatever reason, But when you see people that are dealing with topical staff and you're like Oh my gosh, this needs to calm down like this is driving too much of skin barrier breakdown, which if you don't fix that, then you can't really stop it like you can only do so much from the inside as a kind of mentioned a little bit ago, right? And so if you don't address something from the outside anyway. So I have been pleasantly surprised, and some people it's not necessarily I don't speak for everyone, but in some people it could be really life changing, as you just described. So there are actually some modifications. You just mentioned something that it spawned a question for me. Have you ever tried it with a different agent? You know, if we're concerned that Pearson is an issue for the environment, you know, is there a merit to trying it with different compounds? And then there are some variations in the way people do. The regimen is all

spk_0:   29:18
definitely so. Yes, there's a lot of interest, like what other antibacterial stuff we could use and disclosure is that I worked with a small company based in Memphis, Tennessee, called Fairplex, and I helped put together a product that just came out that is sort of inspired by the Aaron regime, or like a baby version of it. It's an over the counter version that uses a final concentration of 1% hydrocortisone, which is, you know, and all you can do over the counter and instead of antibiotic, it uses natural coconut oil, and it turns out that coconut oil is really, really good for the microbiome in seems to get rid of excess staff and re balance. They've done some studies on it, and I will tell you that it's kind of a neat approach. It's again, not for everybody. You're totally right in my hands. It's like 70 to 80% of patients have a good effect if you picked them, you know, pick the right patients. But there's still a group worth again, whether an offer didn't work for me or, you know, some component of the medicine they're allergic to or can't use. And I don't know if we'll get to the T S W group, the topical story withdrawal group. But I really don't want to use in. People that are have had issues with topical stories, and I want to avoid them completely for that group. So we can talk about that a little bit, too. But yeah, but I think this is another approach, and I think a lot of companies now are starting to try to figure out. Can we use other things besides the mute person? Another person who's really interesting is a guy named Dale Perlman, and he's at Stanford. He's a pH dermatologist at Stanford, and he kind of has his concoction That is really interesting. He uses hand sanitizer, alcohol based hand sanitizer, and he has a kind of wild. But he wrote a little scholarly paper about it to you, and he feels that it has a private, high, similar effect in that it's killing staff. And this time it's using the alcohol. So no resistance issues. And if you put it in the proper set up, he puts it in an ointment. It kind of takes some of the sting away. You got to be a little careful because it is an alcoholic. I don't want to put that, but it really does seem to help some people, so lots of creativity in another area that I'm interested in on to other things just for the future. One is there's a number of stabilized hypo Cloris acid products. They're kind of like the way that bleach works, but much, much milder than using actual bleach. And they're in these hydra gels. There's a number of products out in somewhere coming, and then there's a company that's based in the Netherlands that has a really neat product that is based on. There are those viruses that, like fight the bacteria right in nature, and they've take one of the tools of viruses use, which is this Endo license, and it's extremely specific. It just rips up staph aureus. But it leaves staff up a terminus and all the other good bacteria normal. And you can put this in a low cream base in Robert on the skin, and it just crushes staff without hurting anything else. And it's very, very gentle and you can't get resistant to it. Or at least these guys have been fighting the war for three billion years and nobody's resistant. So really fascinating stuff coming. We think that will be launching in the US in the next few months. So I'm like, there's all sorts of potential to do new things now.

spk_1:   31:54
Yeah, no, these air positive things because the other new exam of drugs I were seeing and I was like, not feeling optimistic about, and this is big. This is big industry, right? So, like we're looking for stuff. But I like you just laid out some cool stuff. What's the company called in the Netherlands?

spk_0:   32:09
That company is called Mike Rios. Microbes in the product is called Glad Skin. I think it's gonna have the same name here in the United States glad skin and disclosure. I have done some advising for them because I stumbled upon it when I was writing a paper and reached out because I was like, Is this for real? Like it's for real. And so it's been exciting to kind of follow them along a little bit

spk_1:   32:27
cool. You know, I have to mention here at this point, once we start to see, like, Okay, cool, we can address topical staff. We could reduce inflammation. We can address things on the inside. I feel like I almost like that exam. A better now. Now that I'm like, OK, yeah, we can predict most of the time improved. I like the things being predictable and sometimes skin is very unpredictable. I had a type of Exuma that waas annoying. I've talked about this a little bit before, not a ton, but it kind of launched after many days in a giant leech bathroom swimming pool and so kind of apparently messed with my external microbiome etcetera. So my question for us, I felt like there was a lot of liver support merited of very poor genetics. For this, Do you use any liver support in practice or is that, like to taboo into alternative for me? I'm like, at the end of the day, we're supporting our internal organs to support our external organs. Not that weird, but what is your vision of that in practice?

spk_0:   33:16
No, I love the way you put it. And I agree. Like, there is a holistic piece to this 100% I think. Yeah. From my standpoint, I don't know if I'd know exactly how to support the liver in the way that you know, for example, a traditional Chinese medicine herbalist would. So I don't know exactly how I would do that beyond some of the things that I do. And I don't know, maybe you could tell me if maybe I'm inadvertently supporting things, not knowing it, but for most of my patients, if not all, I really do want to make sure that they have enough vitamin D cause I feel like the vitamin D is doing a lot of stuff both internally but also helping them fight bacteria. We know it plays a role in some of the antimicrobial peptide, so I want them on D. I do tend to recommend that patients are also taking their couple supplements that I would use. But one of the supplements I've been interested in is probiotics lately. So getting the good, healthy bacteria back, which we know if the liver is failing. Part of the reason that you get this sort of trans location of the bacterial endo toxin is because the gut microbiome and the gut itself is dysfunctional. And one of the theories is that if you add probiotics back, you strengthen the guts. So maybe again, inadvertently helping things out that way. But what do you like to do when you say you strengthen liver? How do you approach that?

spk_1:   34:17
Yeah, so I talk about the liver as a waste processing plant, and it's a busy waste processing plant that's working all day long. And there are bosses. They're like major antioxidants, like Bluetooth I in. And then there's workers. And so these are just like the nutrients that need to show up to do the work. And there's so many reasons of these nutrients can be depleted, right? A and D and B vitamins, etcetera. So if we've got let's talk about these pathogenic organisms like staff arias, they're gonna try to eat up the B vitamins, right? So, like we're gonna a lot of workers, Colin and sick because we don't have enough. So sometimes it's just nutrients, right? Just nutrients, as you kind of alluded to. And I don't think there's one product that doesn't magical job like there is not a product that just addresses this. It's like a lot of things. And there's some other things I look at. It were, The way the skin presents leads me to this. And then, of course, as you were talking about with, like, herbal ism herbs. One of the major ways we think herbs help is to support the body to do things on its own. And so sometimes I'll say, I'm gonna bring in extra workers at deliver, not even extra workers. But I'm gonna help, like fill in the sixth guys right that are not showing up to work because you need these nutrients and just to show up and do this process that makes perfect sense. And then sometimes there's some herbs that seem to in herbal preparations very so much unlike what actually works well, by the way they're created and made so herbs can help stimulate delivered to do its own thing. So I talk about this in terms of the waste processing plant, like hay and phase one. You come in and break down boxes and face to you let him up on the truck, and I'm Phase three. You got to get him out of the body. And so I'm always looking at it, like in a similar way. If digestion has impacted and, of course, things back up on the skin, in my opinion, right that almost like prefer to see that because I'm like a It could be simple. Let's just like open the freeway so the garbage doesn't stink so bad. Right for me, I think of liver related examine stuff like, I think I have a lot of personal experience of that. And then I see it presenting clients a lot, often as well. They kind of the drier skin, and that's not like a unanimous comment here. But you know, whereas the people who are really staff affected bright red et cetera, Sometimes I think of the liver people like there's a lot of history that builds up right, like there's a lot. I have a family history of this as well. And then it's just dry and it comes in on from a different way, right? So it doesn't necessarily come on, especially from an antibiotic round or something like that. But it just kind of mountains over time. Slowly. So anyway, those are some thoughts I have on that. And then there's also some pieces that I've gotten really careful at listening to. People like you have swelling before your period or other things that where you're smelling up because I think about the importance of the lymphatic system. I think it's interesting how some eczema or skin presentation presents in lymph nodes. That kind of bothers me a little bit like Why is it just kind of hanging out there, like in the armpits and in the groin and whatnot? That's a curiosity of mine. I don't know the answer to that, but I think about the lymph system as being how we are getting rid of things as well and not necessarily an expert there. But if people are already swollen, I think that it's probably we need to be real gentle on how we're moving out garbage essentially, and everyone's got a different level of garbage coming in, and that's why it's a little more unpredictable. And I frankly tell people like, Oh, you have a little more unpredictable like I almost prefer the other version we were talking about earlier with the staff of this point, because I feel like it's sometimes results just a little more quickly these options. So let me go back to that really quickly. We're talking about the Aaron regimen and you go on this product. But the goal is to really get off of the product as soon as possible, and people will do this different ways. But my understanding is that you actually don't do it for more than a few days at a time. So you wanna tell us about that?

spk_0:   37:22
Yeah, So it's funny. I kind of live in betwixt and in between a couple of different worlds or maybe many worlds. So I get to see lots of different perspectives, and one world that I'm into that a lot of other dermatologists again, haven't really engaged with is the world of the topical, storied withdraw warriors. I don't know if you know much about them. There's the group that really has been in my opinion really damaged by topical steroids. And I think, probably are as a group. They're different than other patients because I don't think most people will have the same response until you really push beyond the limit. But some of these folks have not used to much at all and then get into this T S w mode, which is maybe I can tell you, is really hard to treat. I'm kind of throwing everything in the kitchen sink and my work closely with a traditional Chinese medicine Doc, Olivia Sue Friedman. And together we really do some heavy duty plans. And sometimes we fail with all of our best stuff sometimes so we can help people course. But it is really tough. So I'm so kind of traumatized by what happened to these folks that I really have tried to internalize, minimizing stories as best I can. So I view them as amazing first moves. When I love stories for us because they are fast, they're really, really reliable. I would say, you know, 99% of patients are going to respond to those stories. They're accessible, right? They're inexpensive, so you can get him, and they have a really good safety history. I mean, they've been really in use since the late 19 fifties, you know, Compound F came out around that time, so we've had some version of stories, and in a weird way, I'm not distracted too far. But in a weird way, they aren't natural product, you know. I mean, our body makes a dodge in. This court is all. So to some extent, your immune system knows what this is now. Obviously, we're using it in the very abnormal way by smearing it on the skin and a high concentration. But still, it's different than some weird, totally synthetic chemical like your body knows what to do with it. To certain extent, that being said, I don't like when people are using them for long periods of time without a break. Dr. Aaron, who I adore and respect, I think he's been masterful. It letting people use it in, sort of slowly taper down over months or even years. And honestly, as far as I can tell, he has been pretty smooth. You know, there's been very, very little long term issues with those patients, which is amazing, and I think in part because he's really watching them carefully, in part because it's a fairly low potency story that we're starting with. But that being said, my goal is still to use thes kind of when you're flaring up pattern and when you're better pattern. And generally don't people do is they'll use that topical story preparation, be it you know, neat topical stories by themselves or in the air and regime or any sort. Do that for up to a week. You know usually say, Yeah, 3 to 5 days get better. We can reliably see that if we're treating appropriately and then ideally come off for a little. And usually for my more modern and severe patients, coming off doesn't mean you just get to just relax. You're still doing all of your regimen. You're still maybe doing your tons of moisture ization. But you may have a nonsteroidal medicine, and that could be anything from topical counselor and inhibitor like tackle a Mr Pamuk Rolla, Miss to Chris, a borough, the newer one that's, you know, sort of anti inflammatory. It's kind of wimpy when you put it on as a start, but it's relatively helpful for some of those patients in maintenance mode or one of my little concoctions, which is pink magic, which is, Ah, topical vitamin D love preparation. That also seems to work fairly well for some patients in this role. Now, not everybody can do that if they're really severe. They're like Doc. As soon as I came down, you know, even though one application, I was miserable. So for certain people, I do follow a more standard Aaron regime. But I try. Always try this way. God forbid, If they do have issues later, it's like, No, look, we really tried to minimize your stories, you know? So I want to be is conservatives. I can. That's a long answer, but

spk_1:   40:38
no, it was fine. I want to talk about a pink magic, but I want

spk_0:   40:40
to

spk_1:   40:40
talk about this a little bit as well, because one of the contra indications with wet wrapping, which is what some people use, is that you're not so so using your steroid cream under the wet wraps, because we think it affects the adrenals more so and then when we think about kids, this is concerning. I've just been thinking about this a lot lately, you know, when we think about kids, we are sister not be on steroids very long. I mean, they have ah, surface area to body weight that's different than adults. And so we think we're absorbing more. And I spent part of my morning talking to the medical director at a hormone testing company. I was talking about what we see in adults with metabolized cortisol and essentially, when we're using in topical steroids or nasal steroids. Inhalers for allergies were taking whatever in a short amount of time, our body stops producing the level of cortisol that would normally like that and flow. We're just half court is all in the morning so we can wake up and it's about to go down in the evenings and go to sleep. And that starts to get upside down for a lot of reasons. Stress. The night time scratching can really impact this whole thing, right? But I'm just thinking about this a little bit because this is kind of I'm just rolling it around in my head, and so basically, we're putting this on, and our body says, Okay, we've got enough court is out. You know, we got enough hydrocortisone or We've got enough quarters, all stores now. So, like we're good, we can shut down production. And so we shut it down. And so the whole thought process behind tapering off of steroids means we're not rebounding as much. Or it's really hard on us and rebounds. And I just think about people who are unable to taper off. And I wonder if the exhibit has already created so much stress in their life that they're D h e a. Let's say is really compromised. And so they don't have that because that helps kind of buffer and help rebound it. So I just kind of wonder like these will be hard people Thio look at hormones and because they're gonna be a little skewed when we're on steroids anyway. But usually D A. D. A. Is not really affected by that. So anyway, I'm just rolling around in my brain. The other things that are going on that may help them come off of those steroids a little more simply like there's a reason that some people cannot come off as easily as others, you know. And it's the whole compound of their history.

spk_0:   42:25
No, you're right. And I think it is a complex route. But for the reasons you say the sleep is activated and disrupted their action in a huge amounts of stress, and we know you're right. Court is all the stress hormone. So how much is chicken and egg now? The good thing is there actually is part of getting FDA approval for topical stories. They actually have to show absorption, and they have to show effect on the adrenal. So the good news is that most of the stories were using, and kids have actually been testing some of them for many months at a time. Even so, you actually can get a sense. So they do that court stim test. They can actually see how your adrenal gland is responding. And generally speaking, the absorption is so low from a system wide perspective for most people using incorrectly that it's not an issue. That is, of course, not true, though, when you put people on oral steroids and one of the crazy things we see in some of my colleagues, you know, particularly don't pick on pediatrician, the wife's a pediatrician and we love our pediatrician's. But sometimes they'll be very nervous about topical story. They'll say what Gosh topical story than this. You know, this two year old on his face like, don't you think it's dangerous? And I'm like, Well, kinda. But then this is the kid you gave last week of prednisone pact. Remember? You gave a doom and it was pumping through the blood vessels in his eye. You're worried about putting a little cream around the high? You have just pumped it through the eye and they go, You're right. I didn't think about that. So by and large, I see Well, hey, Maur issues with systemic corticosteroids than any topical stories. But you're right. You can mimic systemic stories. If you put enough on in the high votes, then you actually do have an absorption. But fortunately, most of the time, we're below that range.

spk_1:   43:47
Yeah, I guess a couple of factors here are is that a lot of people get lost to follow up or, you know, there's no follow up on. Let's taper off of things right, because we're not meant to be on things, necessarily forever. And there is misuse accidentally, right? Like it just happens Sometimes there's not enough time to educate people on, like they were not sort of using this, Oliver. And hey, if you're miserable, what do you want to do? So it's a tricky situation. I'm curious we have. I mean, we don't have all the answers to this or maybe not enough time talking about. But I'm kind of curious on how they're measuring on, how they're looking at the adrenal response as well. But that's good to know. So thank you for that. Okay, let's talk about why you're a pink magic cream with B 12 works topically, because that's not something I have seen a lot of.

spk_0:   44:21
Yeah, this is something that I came across in the literature. There were a number of Phase three studies looking at topical cab element vitamin B 12 and the thinking is that B 12 topically applied seems to inhibit nitric oxide synthesis, which is one of the triggering factors. It's so thought, one of the tricking factors for inflammation in Exuma and they did these trials and actually showed that it was significantly better than the vehicle. And I read these papers and I'm like, Wait a minute, these are like more than 10 years old. Where is this Why don't we have this? But for reasons I don't understand, it didn't seem to be a product anywhere, even though someone was clearly looking to make it a product or studying it. But I couldn't find it. So I talked to. We have a local kind of, ah, herbalist and he does all sorts of neat stuff with different natural botanicals and plant oils. He's kind of a natural person who puts wonderful product together. And I called him up and I said, Ted, can you do this? He's like, Sure, he's like it's kind of simple. We just get the V 12 powder and we'll make a really good base and we'll kind of follow what they did in this article. And he made this beautiful stuff, and it turns out B 12 powder is like crimson, crimson, crimson, red. So when you put it in a white creamy base, you get de saturated red. You get beautiful pink, so it's obvious that it's gorgeous, and I've been using it for more than a decade now. So I used it to my daughter when she was first born because she had some excellent. So I got to use it on her and she is over 10 now.

spk_1:   45:38
Very good story. Interesting. And maybe you should have a storefront. Dr Leo. Well,

spk_0:   45:45
you never tell.

spk_1:   45:46
Yeah, I mean, 10 years, Maybe I'm gonna do something different. So anyway, um, this was so fun to talk about all these things because I feel like, you know, we have some mutual friends, colleagues and one of my friends who has a podcast about skin. She said it's hard to find people to talk about this that know much about skin. So it's always fun to, like, just be able Thio mastermind a little bit about what's kind of going on on the underside of what's going on in the outside. So where can people find you online? Dr. Leo,

spk_0:   46:14
The best place to see what I'm up to you and what I'm working on is our Chicago exam, a website. It's www dot Chicago exam a dot com, and we also have a Facebook page. It's like Facebook slash shy Exuma, and you can follow us there, and I always try to update my papers and where I'm talking about who I'm hanging out with and who's shadowing and all this kind of stuff on there, and we do. Every other month we have a live meeting which anybody's in the Chicago area or not. People come in sometimes from out of town or if they're visiting, we just do an open group. There's no fee. We usually have a little light breakfast and coffee, and that's usually on a Saturday and I will update the still says October on the website. But all updated very soon as we get our January Deeks, we're gonna push off through the holidays until January.

spk_1:   46:53
Cool. Well, you're really a service to the exam, A community. Thank you so much for what you do. I know it's a big topic, like people want it to be very quick and fast and topic like an external solution. And sometimes it can be quite a bit more than that. There's just a lot of different topics to talk about. I feel like more so than other conditions. It's internal, external and everywhere else in between, right, because there's a whole wild card with stress. If you could leave people with one gut reaction if they're listening today and they're like, gosh found this really great But there was so much information. I don't know where to start. What would you say to them?

spk_0:   47:24
I would say that Exam A is a serious problem for a lot of people and causes a great deal of suffering. It's not just a little rash. And even though it is super complicated, honest to goodness, we can help a lot of people. And by working together with lots of great thinkers and lots of team approach to try to find the best solution, we can get many people better so that they can go back to their life

spk_1:   47:45
was great advice. Thank you so much for coming on. Hopefully the have you back again.

spk_0:   47:49
Thank you again for having me. I'll talk to you soon.

spk_1:   47:51
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