Episode 05: How to Determine What Skin Products To Use And What To Do About Acne, Eczema, Dry Skin, Etc.

Hello and welcome to The Better Biome Podcast, where we explore the universe within. There is a complex and mysterious community of organisms that lives in, on and around us, that have an impact on every part of our health.

These communities are called you biomes, and we're here to explore all the different biomes to help you and your family be the healthiest you can be. We're your hosts, Dr. Nicole Beurkens —

And Kiran Krishnan.

And on today's show, we're talking with Dr. Raja Sivamani about the skin microbiome. Dr. Raja Sivamani is a board-certified dermatologist and practices as an integrative dermatologist at Pacific Skin Institute. He is an Adjunct Associate Professor of Clinical Dermatology at the University of California, Davis and Director of Clinical Research and the Clinical Trials Unit. He is also an Adjunct Assistant Professor in the Department of Biological Sciences at the California State University, Sacramento and an Associate Professor of Dermatology at California Northstate University, College of Medicine. He engages in clinical practice as well as both clinical and translational research that integrates bioengineering, nutrition, cosmetics, and skin biology. With training in both Allopathic and Ayurvedic medicine, he takes an integrative approach to his patients and in his research. He has published over 100 peer-reviewed research manuscripts, 10 textbook chapters, and a textbook entitled Cosmeceuticals and Active Cosmetics, 3rd Edition with a passion for expanding the evidence and boundaries of integrative medicine for skin care.

Oh, I'm so happy to be here, that was a really awesome introduction guys. I'm looking forward to talking to you.

Yeah, you sound really lazy! Pull it together, do something!

I don't know how you have time to see patients with all the teaching and the writing, it's really impressive!

I try to keep busy.

That's good. Well, you do some things, a lot of things with your work that are really innovative, that most dermatologists are not doing. One of the things that I think are so impressive is that not only are you doing that in your own practice, but you're really focusing on writing about that, teaching that, training other people in your field to be able to help patients with the kinds of innovative things you're doing. I'm curious for you to share with our listeners sort of the journey of how you came to be doing this innovative work because you were trained as a traditional dermatologist, right?

I was. You know, just to take it back a step, actually, it all started with what I thought was a failure when I was much, much younger. I applied to medical school right out of undergrad and I didn't get in. I thought that's it, this is over and I'm not going to amount to anything. And for anyone that's listening out there, failures are just probably the seed of a future success. You just have to put the right mindset. When I didn't get in, I went into bioengineering thinking, "Okay, let me do this." And I met one of the most fascinating people that's been my mentor for many years. Even just the other day, he sent me an email saying "Raja, you should follow up with this company, call me." He must be close to 90 now. Howard Maibach. I just want to call out his name because he's been so amazing to me. And from there, when I went into engineering, I started realizing, "Oh, I'm really fascinated with skin, but I'm more fascinated with psychology and interacting with people." Because he did that. So I went into dermatology, and you're right, I did traditional training through medical school. But then I realized I was missing something with just going a little extra step deeper in connecting with people, learning about imbalances and also getting a framework for nutrition. A lot of us in medical school don't get that much nutrition training but we all wish we had more. So I went into Ayurvedic training and it totally changed my life.

I think in that sense, when I went to Ayurvedic training, I had to start really thinking outside the box to connect the dots. I think that really stimulated that research side of me even much more, so it's been a really amazing journey. I now think about how you connect Ayurveda to the western standard research paradigm, then I did basic science training as well and tried to meld it all together, but like you said, the whole goal is: Can we get practical next steps for my patients?

Yeah. You know what, Ayurveda, for listeners that aren't familiar with that, that's traditional Indian medicine. It is actually still, in many parts of the country, the predominant form of medicine in India, and not necessarily the standard allopathic. What's interesting about ayurveda, and maybe this applies to you as well, I grew up in India, my family is from India and I think your family is from India as well, both from the south. There are ayurvedic components within just daily living, right? In terms of eating, fasting, meditating. There are home remedies that are really powerful in many ways to certain things. So even though you started your journey into the allopathic training world, did you always have in your tradition, in what you did, the way your mom did things, that were Ayurvedic in nature?

Yeah, there's no question. My mom would give me all these tidbits. What teenager is going to follow everything? But she'd say things, like after I ate a really spicy meal, she'd say things like, "Oh, why don't you have this yoghurt to finish it off?" And I'd be like, "I'm good." and then I'd go out to start playing sports or something, I'm like, "Oh man…" that indigestion kicked in! I should have listened to mom! Or she'd be like, "Oh, why don't you take some turmeric" and this and that, "Put it in." I'm like, oh you know, "What's the science behind this?" Like you're a know-it-all. And then of course, after medical school and everything I'm like, "Hey mom, about that turmeric… Yeah, I think you got it right." Like mom's right again! So it was definitely there. Oh lemon water, absolutely, every morning. Even when I go home now, she's like two things: Lemon water and don't drive too fast because the policemen are everywhere.

Words to live by, really.

Absolutely. But it was definitely a part of me growing up. I mean there are always these conversations about heating foods, cooling foods, making sure that you get enough sleep and making sure you also stay active and keep yourself engaged. So I think it was always there in the background, and I think it did drive some of my thoughts about, "Hey, where can I think about lifestyle a bit more when I'm thinking about patient care?"

Yeah, and the fact that you didn't go right from undergrad into medical school, you actually took this tangent because of what was perceived to be a failure at that time, and I'm sure your parents were like, "Oh my God, you didn't get in!" That's a scary thing for an Indian family, right? Let alone someone like me who didn't even apply for it, that's a very scary thing! But how do you think that shaped the way you thought about medicine and science once you started medical school based on your newly-formed mind? I mean, you were firing different neurons, going kind of the engineering math realm, right?

It totally changed my experience in a good way. First of all, my parents were actually really, really supportive, because my dad had been like, "Hey, maybe this is a chance you can go into computer science!" I was like, "No! Let me just take this path." You know what it taught me? It taught me that these journeys can't be pre-planned, that you've got to just let the journey take it the way it's going to be. It goes back to that quote, and I even mentioned it at the Microbiome keynotes, it's one of the things that I talked about, it was like we're on our way, but we don't know exactly where we're going, but I know we're on our way. So I've kind of imbibed that mentality. So whether it's research or a difficult patient or some question that I want to get an answer to, I try not to overplay it, and just let things come. I've found that the less I stress over it, the better chance I have of trying to find some nugget of information that I didn't want to miss. I stay a bit more, I would say alert and attentive for it.

It probably stresses your patients less that way too, the less stressed the practitioner is, right?

I think that's true. I think that's very true because they feed a lot off of how you perceive their condition. So if you tell them everything is going to be okay and you really take that approach, I think it calms them down, and that is a side effect of the whole thing.

So, most people, their experience with dermatology is "I've got these skin issues." right? "I've got maybe some eczema/my child is struggling with acne or psoriasis, things like that, and they go in to see their primary care physician or dermatologist, they're told, "Here is some cream to put on that/Here is some medication that you can take." You really back things up, though, more to root level and say, yeah, some of that can be helpful, but we really need to look at the health of the skin from a more root level. And you talk about the microbiome as being related to that, which I think most people go, "How are those things connected?" Right? So I'd love for you to talk about that root level and the microbiome connection to skin.

Yeah, you know, I think one of the things about the skin is it really — and we talk about it sometimes, it's almost cliche that it's a window into the person, but it really is, and actually, a lot of dermatologists will pick up on things that people might not even realize, and we might not even talk about in the room necessarily when we first meet someone. There are certain skin findings that make you think diabetes, there are certain skin findings that might make you think you might have a really high lipid level or some cholesterol level. So there are things that we pick up on, but like you said, even this microbiome, it really goes back to the journey with nutrition and ayurveda. Because in Ayurvedic medicine, again, this traditional form of medicine from India that really had empirical knowledge that's built up over 5000 years, they talk about what's known as the gut-body connection. So the gut health, then leading to blood health, leading to however your tissues are going to be, whether it's in health or not in health. That made me start thinking about if I'm looking at skin health, it can't all just be from the outside, there's got to be something from the inside.

And the thing that triggered it for me was there's this one finding on the skin called acanthosis nigricans where you get extra dark markings and kind of velvety thickening in the skin folds and the neck and it's a marker of changes in insulin resistance, and that's what really got me thinking, gosh, we should be having holistic conversations with our patients because this might be the only chance that the child comes in, that they're going to hear it from someone. Sometimes people don't even pick up on it. So I really try to make it a point, like you're saying, to talk about: Someone comes in for something. If I pick up on either a psychological issue or something that might have some metabolic issue or some long-term issue with health that could be much beyond anyone one organ, I try to make it a point to not only talk to the child or the person, but also bring it up as a way of, "Hey, the lifestyle matters." I think when we talk about root cause, I think that really matters. You have to change lifestyles to get to the root cause. And yes, the microbiome, the gut microbiome, I'm probably the most fascinated with the gut amongst most of my dermatology colleagues. So I really think it's powerful to start looking at that level.

I think this is one of the most fascinating areas, just to think about the gut connecting to the rest of the body. Absolutely. In fact, even if you look at the embryological origins, we know that the brain and the nervous system are connected to the skin, so right there, we know that there are much deeper connections than just the skin, absolutely. And then with the gut-skin access, when we think about it, even the simple concept that what you eat can change the way that your skin is going to get nutrients, right there is a gut-skin access. But now we know that at the gut interface, there are things like T cells, T regulatory cells, T 17 cells, and that obviously ties into the immune system. And then some of the research that we're focusing on is: How do the shifts in the microbiome — Does that change the lipidome and things like short-chain fatty acids, saturated fatty-acids and just the fatty acid profile? How does that then connect to the skin? Because there's a portion of the skin that's right next to the blood flow: The sebaceous glands, the sweat glands, so there's definitely this potential for a connection and we have a lot of traditional medicines like traditional Chinese medicine, naturopathic medicine, Ayurvedic medicine, they all talk about this gut-skin access. What I like to do on the research is: Can we find these biochemical pathways so we can better understand and help evolve not only western medicine, but evolve traditional medicines too? Because we're all evolving together.

And one of the studies that you've shown me that I've seen is on the carotenoid absorption, right? The use of topical carotenoids versus ingested and where that shows up in higher concentration. And for the listeners that don't know, carotenoids are these antioxidants that are really important for the skin, they are present in colored fruits and vegetables and so on, which are really important for the skin. And I think you showed a study, certainly at this conference, we were at the Microbiome Keynotes for people that are unaware, this is a microbiome conference of the leading researchers in the field and Dr. Sivamani actually presented here. That slide was really fascinating. Can you elaborate on that a little?

That was a study that was done elsewhere but it's really fascinating because it's looking at the amount of carotenoids. Carotenoids are a phytochemical that is naturally — it doesn't have to come from plants, bacteria produce it too, but basically a class of chemicals that have these properties that can also be photo-protective and it's found in a lot of colored vegetables and what not. The study was looking at: If you paint them on topically on the skin, as opposed to taking the dose orally, how well do they get into the skin? What was really fascinating was yes, of course if you put it right on the skin, you think it's going to get right on the skin, but taking it orally also honed to the skin, so it speaks to you how nutritional input can somehow find its way to the skin. As an engineer, I'm like, how did that happen? I want to figure that out because we need to hone in on that. Some of the research that we're doing now that kind of works on that is we're doing some whole foods related approaches. We just completed a study on almonds and wrinkles in post-menopausal women, we're doing another one with mango intake, another one on walnuts. There's going to be a publication that's coming out later this month that's going to focus on almonds and wrinkles, so watch out for that. I don't want to give away —

I'll be watching for that, okay!

I don't want to give away the secret sauce, but it's going to be coming out soon.

Alright, we'll watch for it. Everybody's ears just perked up! So food matters. Not just for our — people think about digestion and things like that, but what you're saying is the food that we take in matters for the health of our skin and the appearance of our skin too. I'm curious, what are some of the common things that you see patients or people in studies doing that really are detrimental, even for their gut microbiome that then impacts their skin, or maybe are directly negative for their skin?

There are so many food options nowadays. One exciting thing about the landscape of how people think about food now is that we're talking about it. Thank goodness that this gut microbiome and just the microbiome in general has really opened up the conversation about nutrition. So now, people are really looking at whole foods. And one of the things that I've seen that is detrimental is we really can fall back on processed foods with the preservatives. We don't fully understand how that's going to shift the microbiome, but one thing I can say is you feel a heck of a lot better if you eat whole foods and locally-sourced foods. And it's also lighter and easier to digest, I find. Not only is it good for skin health, I think there is also this mental connection with the food, and I feel like that's really important. Because I know personally, and I know a lot of my colleagues and even my patients, when they start eating locally-grown foods or even cook the food themselves, they develop a better relationship with food. I think they actually just feel better. I think the feeling better then ties back into that little tiny hit of endorphin, that's like hey! I'm doing something good for myself and I feel good about it. I think that just snowballs on itself.

So some of the detrimental things that I can tell you is not having a regular schedule, eating really late, irregular, I mean all these things are so easy to do in today's society because we just don't have time. We're trying to eat on the go. And I think that the most challenging thing is if you're traveling a ton, and I'm sure both of you know about this, you guys travel a lot: It's so easy to lose sight of what it means to eat healthy there. So even if we can help people think about how to eat healthy, eat healthy snacks, it makes a huge difference, I think.

Are you seeing anything specific with acne, for example? That's a topic that always gets people's attention. In terms of diet, or the risk of making your acne worse or trying to improve by making changes in the diet?

There is so much more evidence coming out now, and one of the things that was striking to me when I was in residency was we thought that acne didn't have any role with diet. Now it's almost like people will laugh you out of the room if you say that because there are so many studies coming out. For sure, there are some clear associations that seem to be emerging. With acne, the intake of milk, especially low fat and skimmed milk, there seems to be an association, an epidemiological study after another study, they're showing this association. We've done work on cells, we work sebocytes, we've shown that when you expose them to the proteins that come from milk, that can stimulate the oil glands to start producing more. And actually, what's really interesting is there have been case reports now showing that if you have kids that take whey protein, you know because you're trying to put on weight, muscle, especially amongst athletes, this can be an issue, they'll break out with acne. Stop the whey protein, the acne will go away. Then they restart the whey, then the acne comes back. At some point you're like, well we don't need to go through the cycle over and over. So that's one thing, but another aspect is it's not just what foods aren't good for you. What foods are good for you? So there is this notion of let's focus on low glycemic foods: Foods that aren't going to be like refined sugars. Sweetened teas have now been shown, in Asia there was a study that sweetened teas — you think that teas are healthy. If you put a bunch of sweetness into there, artificial sweetening, it's also associated with flares of acne, worsened acne. Same with sodas. Basically every teenager's dream, right? Strip it all away.

Taking away everything they love.

But if you focus on a low-glycemic diet and something like a mediterranean diet, that has been shown to be helpful for acne. So I try to have these conversations, if at the very least, let's get them shifted away from the low-fat and skimmed milks to something different, I think even that I feel is a big win.

When you talk about milk and dairy, specifically cows milk and dairy? All animal dairy? I'm just curious.

It's a really good question. I think most of the studies have really just asked — some of it has been recalled, and by and large, what people drink is cow's milk, so I'm assuming a lot of that is going to be centered around cows milk. Now, if you want to split it up amongst like — believe it or not, we're actually working on a manuscript now that just details what are the differences between the different kinds of milk. So we're going to be looking at what's in cow's milk, what's in goats milk. Camels milk is now making a big run. So there are a few other kinds of milk, sheep milk — so there are a few other kinds of milk and we're going to be looking at what the kind of nutritional load in there is. The next level of studies, that needs to be done. But I think by and large, a lot of it is centered around cows milk.

I think that will be helpful for people, because from the practical standpoint, when you say to a family or a teenager, "You need to get rid of cows milk in your diet" they go, well, how do I cook? I can never have pizza again, or whatever, I think it will be interesting because it would be nice to know, could they do sheep cheese for example or camel milk or something like that to be able to have some of those things in their diet? Is there something specific to the kind of milk? I know what I see just anecdotally in practice, but that's really helpful, practical information to people, especially a 15 year old that feels like you basically just told me, "I can't ever go to a birthday party and eat normally again." So I think that's really helpful research.

One thing that I've made it a point to do with patients is to never be the guy that focuses or nevers. So if they're going to go to a party and it's a pizza party, enjoy the pizza, if it's once in a while. But I just want to make sure that they are conscious about it. Like, "I'm going to make the choice today to eat pizza." If they're going to do it, great. That means they're thinking about it. I just want them to have that forethought before they eat and just be mindful of that. But you're right because one of the things is if we talk to them about stripping everything away, they're like, well, "I can't go to this party with the celery leaf in my hand", so it's like "Oh yeah, great microbiome but I'm not really connecting with anyone." So I try to tell them to be reasonable about it.

This may be a two-part question, but the first one is, you mentioned earlier that you're seeing some sort of benefits with almond, which we're not going to say much more about. So do you think that same benefit can come around from drinking almond milk instead? So maybe switch from dairy to almond milk. Not only will it help not flare up the acne, but maybe it will have the other benefits which you're going to publish later.

We're so lucky in California because we have all kinds of milk here. We have cashew milk, almond milk, macadamia milk, flax seed milk, qui milk, coconut, oat milk is now another one.

You can buy it online.

But in terms of almonds — I do try to get them off-dairy to some other dairy alternative. I think what's really important, no matter what kind of milk they go to, whether it's macadamia or cashew or almond is don't get the milk that's sweetened because then that kind of defeats the purpose. They're still getting a load of sugar and another insulin spike. So I tell them to get the unsweetened. You know what's amazing? I tell them — and I try to preface it "When you change, it's going to not feel normal. Not feeling normal is a good thing in your case because you don't like normal right now because your normal is acne." I try to walk them through that and they come back, and they're like, "You know, it felt a little weird the first time when I started it, but then I got used to it, and yeah, you know, actually, it's not bad!". And I'm like not bad is a win! That's a major win. And then the parents are like "They're becoming really stringent about the milk around the house" and I'm like, "Sorry that's your problem." It's not my problem!

That's going to benefit everyone's health because the reality is usually everybody's got some things going on, they can benefit from some of those changes.

Just starting to think about nutrition in general.

So one question then about food: We're talking about how the food can flare the acne, right? But if you take a number of people and all of them have dairy, just a small percentage of them will actually have an acne flare. So then the question about that is, obviously people's bodies are reacting differently to the food. The people that are susceptible to the acne flair from the diet, is it something wrong with their gut or is it something wrong with their skin or is it a combination of the two? What is driving the risk for the food not agreeing?

Love, love, love this question, Kiran, and I think it's such a sensible question in so many ways.

I am very sensible.

You're a sensible guy! I really love the way you pose the question because we want to rush and say that one food is bad for acne and it causes acne. I think we have to be careful. It's the people that already had acne where they already take a certain food and they were already having that tendency to flare for acne, then they flare with acne. But taking myself. I can probably count on one hand how many times I've had a pimple on my face. I just don't have that natural tendency, be it genetics or be it environment or whatever it is, I'm not going to flare with the acne. So for me, if I drank a bunch of milk, I'm not going to start sprouting acne all of a sudden. So I think there is a little combination of what your predisposition is in your skin and what your predisposition is in your gut, then your sentivites that come from that. So there can't be a one-size-fits-all. I mean in general, we're all unique. If there's anything I learned from Ayurvedic medicine, and even western medicine, now we're starting to really subtype people: We're all unique. So you can't give a one-size-fits-all solution to everyone. You've got to — and even when we make generalizations, we have to be careful that we don't overgeneralize. So I think it's true. I do think that if your skin is set up to go in the direction of eczema or in the direction of acne, then you have to be a bit more careful about those triggers.

So I think that issue of triggers is a big one. You were talking right now about milk, but that sort of leads me to think about what are other environmental triggers, things that you see that really can cause various types of skin issues to flare for people?

Absolutely, I think the environment plays a huge role, and sometimes it gets underestimated. For example, if someone is living in a humid environment and they have a tendency towards eczema, that water content in the air is actually going to be soothing to their skin because they naturally might have a skin barrier that loses water. This is one of the problems in eczema in general: You can't hold on to the natural hydration, you just lose it. So if the environment can help you, that's great. Now take that same person and send them to a place with high altitude like Denver that's very dry, or if you go to some of these cities in New Mexico, they're high altitude, now you're starting to lose water like crazy through the skin, you don't have that water content, and you flare.

I know that even personally — and I have a tendency towards eczema, when I went to one of the recent American Academy of Dermatology meetings in Denver, the first thing I did was I went straight to get my moisturizers because I knew I was going to flare. So the environment plays a huge role. On the flip side, if your skin is very congested as it is or has a tendency towards congestion, then you put yourself in a hot, humid environment, you're going to develop things like folliculitis a lot faster, your pores are going to clog more, so I think environment plays a huge role, and we can use that to our advantage. So if you have a child with eczema, I will talk to them about humidifying the air. Now, is that the end all, be all? Of course not. You have to have the holistic approach. But you might as well include that as part of the holistic approach and be mindful of the environment, so I think it does matter.

You know, that brings up a question for me then, since environment matters, obviously one of the biggest exposures to our skin is the stuff we put on it, right? The personal air products.

The envirobiome. Quickly, call my lawyer and patent that. EnviroBiome, trademark!

But you know, one of the things that I learned from getting to work with you and talk to you, is obviously you're doing great research, you're teaching, you're seeing patients, but you're also building this amazing tool that I want you to talk about a little bit, you know? There's a website called where you've invested so many resources into providing an amazing amount of education on that website and you've got the skin-typing tool, which I've done myself, and it has some fascinating applications to it because it really gets people to know their skin type. So can you talk a little bit about the tool, what it tells you at the end of it, and then what the utility in it is? What can people do with that information?

The reason we came up with this tool in the first place is I was starting to see how frustrated patients would get when they try to ask about what product they should use. It kind of becomes a trial and error wild west, and you go off of "What did my friend use?" And I started thinking about it like, whether you go to any website, if it's a large distributor of any sort of skin product or any product in general, sometimes you look at how many stars there are. But how do you know that the person that rated that product has the same tendencies that you do? Just like we were talking about, someone who has a tendency towards acne was like, "Don't drink this, it's horrible for you." And I drink it, I'm like, "I did great!" It just speaks to how unique we are. So the reason we built this tool, it's really just a pretty quick quiz. It goes to different sorts of tendencies that you might have with your skin. Then we build in things like stress, sleep, anxiety and how restful you feel, and then gut health as well. The idea is like: Let's get a profile on people, and then see if we can use that profile and create an algorithm that can match people to ingredients that make sense. Because really, at the end of it all, it's like match.com for you. You might not find a great marriage partner, but hopefully you'll get a great regimen.

At least you'll look good to find a partner because your skin will be healed.

Yeah, exactly, okay! Trademark! But in general, the idea is can we type people? This really comes from my love and wanting to work in the space of, how do you take the general knowledge of research? The general knowledge and the rigor of western approaches and build in all this really empirical knowledge that's been built up from traditional Chinese medicine, Ayurvedic medicine — so that all is actually built into the backend of this tool. Then what we try to do is we try to give an output of what your skin type is going to do, and what kind weather would make sense. We actually went through and looked at all the different climates and we actually called each of the skin types by different climates. So basically, if you are a desert type, you are really dry and going into a desert climate might not be so good for you. We kind of go through that and go through what kind of regimen would make sense, what kind of food would make sense. How about exercises? Think about if you have rosacea or if you have really bad acne, doing something that's like hot yoga is actually not that great for you. Sometimes people are raving, like "Oh, hot yoga is wonderful." Not if you have rosacea. It might not be so great, because you'll flush like crazy. So you might want to do vinyasa yoga or some other form of yoga. So we talk about those kinds of approaches, and then we kind of put it together with an Ayurvedic description of what's going on too, but the idea is just: Let's get educated about who we are a little bit better and then help you make better choices as you go forward.

One of the things — and I got to see your typing tool which is really phenomenal. It's such an easy, free quiz on the dermveda.com website.

And we'll make sure to include that with the show notes too so everybody can click on it and access it, yeah.

It gives you so much information and I know, you showed me the backend of what you guys have done and you've gone through literally tens of thousands of ingredients that are commonly found in cosmetic products and of course then there is a matching where someone could look or scan in someway the personal care product and the tool will help them — maybe now or maybe in the future?

It's coming up but that's exactly what we're going to do because we went through ll these ingredients and looked at — like a small little thing, if you have really dry skin and your skin product has a heavy load of emulsifiers, which can dry your skin, then we billed it down to common sense: "Drying agent with dry skin, not good" kind of a thing and we tried to build it so that then you can type the products and then figure out based on the ingredients — we stay agnostic to brands, I just want to look at the ingredients and strip away all the other baggage and say, hey, how does this work? It's going to be coming out soon.

Yeah, and a consumer would never know what an emulsifier is. You wouldn't know it if it hit you in the face. And there could be 7 of them in the product that you're taking.

And even if you did know what they are, then it becomes like it's more of a "What do I do with this information?" That's the one thing, even when we talk to patients, if you give them information overload without a simple way to address it, then they just walk away educated but no solutions possible, right? It becomes a real challenge. Even from the practitioner's side, I think one of the things that I love about what you guys are doing is building together — even the Microbiome Keynotes that we were just at, bringing practitioners together to start talking about a lot of these sorts of different approaches. Yeah, I mean I think you've got to make things practical. You've got to make things really easy.

So you're talking a lot about the individualized nature of these things, right? What works for one person may not be effective — maybe there are some general principles but really, this individualized piece, that makes me think about the whole realm of probiotics, right? So we're talking about the gut-skin access, the connection and "Okay, so I need to do something to improve my microbiome, let me go take a probiotic" what do you find is important to consider there as far as individualization because there are certainly, at least in my experience, it's not a one-size-fits-all as far as probiotics go.

Yeah, it probably goes back to one of the adages that you can use in almost any field that an X is not an X. So a probiotic is not a probiotic is not a probiotic is not a probiotic, in the sense that sometimes we use the term as if it just generalizes the entire field, but the exact bacteria that you use, whether it's lactobacillus or bacillus, one of these foreformers or if it's like a bifidobacteria, I mean all of these are going to have different effect and they work in different ways. Now we're starting to see from science that certain bacteria or certain groups of bacteria put together may have certain functions in certain areas. For example, lactobacillus rhamnosus gg, that one has been shown to have a bit more of an effect when it comes to skin with eczema. A lot of studies are starting to look at that. Or perhaps with itch. Then on the flip side, sometimes you have these sporulating bacteria that can take hold and then they can get through the gastric juices and they don't just die right in the gastric juices. They've been shown to enhance what's known as akkermansia in the gut and maybe produce more short-chain fatty acids. And then that has some end effects.

So I think eventually, as we start to understand the science, we'll start to see that you can't just do a one-size-fits-all, and you really need to pool in different sorts of bacteria and different sorts of probiotics and prebiotics too. Let's not forget postbiotics and prebiotics. Prebiotics are those substances that can help bacteria bro, and postbiotics are actually like the coolest thing ever. Postbiotics are basically the metabolites of bacteria and can you use that to then harness that and deliver that to people. I mean, what a time to be alive. I'm going to credit my student with that, by the way and I'm going to have my student listen to this podcast, what a time to be alive! He actually published a paper and said "What a time to be alive." Something along those lines, I thought. You love that enthusiasm.

So, with that in mind then, somebody is listening to this and they've got skin issues. Obviously now, after listening to this, they know their gut has something to do with it and they are thinking about a probiotic, what are the chances they are going to find a probiotic that's going to be effective for their skin if they go to their local drugstore or local club store and grab one of the many things that are on the shelf?

Probably the biggest challenge there is, because it's so hard to know how these probiotics are made. I really think this is one of those things, you can't fast-forward science. You really have to look at those companies that are putting time and energy into research. It's putting one step in front of the other, so try to find those companies that have research backing behind them. I know it's a little extra time, but if this is something you're going to take every single day and you're going to ask your family to take every single day, gosh, if we're worried about whether it's locally-sourced or organic for our foods, shouldn't we have that same sort of approach with our probiotics? We should be focusing on companies that care about research, that care about getting good science out there, not just a quick buck because they're going to put something on the advertisement label. I think that's where it becomes a challenge and I think this is where your practitioners that you are going to see, they need to be educated on probiotics and they need to be able to know who is really focusing on the research and doing a good job and who is publishing. I think all that matters.

Well, just as they manage the medications you take because they have the knowledge base to do that, and that's how they make those decisions to help you, supplements and nutrition and all of that is the same, they can be so powerful when you choose the right things, right? And certainly do nothing if you choose the wrong — or even in some cases, do something adverse.

And the last thing you want to do, even as a practitioner, you don't want to recommend something that at worst — at least if doesn't harm someone, fine, but the worst thing you'd want to do is give them something that's going to make them feel worse, or let a lone throw a bunch of money at something and maybe there is no effect. That's why it's very hard if I see someone advertising a certain thing. I want to know what the studies are. Maybe that's the practitioner in me. I'm like let me see the data, let me see the evidence. And if we don't have evidence, let's do a study together, let's figure it out.

I think that's so important and that's really part of our goal in having this podcast is to help people understand the research enough to help them make informed decisions, because usually you go and you stand there and you go "There are so many options, what do I believe and what do I not believe? I don't even know how to go to PubMed and look at all that" so that's really one of the big goals of having researchers and practitioners like yourself come in, it's to help distill the things that people need to know from the research, that they can make informed decisions because that's so important.

Well look at the food pyramid, right? Let's just call it a food merry-go-round. It's just like spinning all the time, and one year, the next year — it's like if you went in a time capsule and came out you'd be like "What the heck is happening!" it's always shifting! The funniest thing — it's not funny, it's actually not so great that we did this, but as recent as maybe 70-80 years ago, we had physicians smoking cigarettes saying, "Hey! I smoke this cigarette, you should too!" And now you're like, what the heck were we thinking? Part of it is that science evolves and we just have to stay humble and realize that education helps us learn how to learn but then it's still on us as practitioners and also in developing good, healthy relationships with industry to move that forward, ethical — and also just information, fact-finding way that's trying to focus on trying to get the right result.

I've heard you — we were talking about the gut microbiome as it relates to skin, I've heard you talk about interesting things related to the community of microorganisms that live on our skin. I heard you talking about eczema and staff and topical applications of things like probiotics. I think a lot of people don't realize that we have the communities of microorganisms that actually live on us. Can you speak to that a bit?

Absolutely. In fact, sometimes there's a little debate between — and my bias is obvious with the skin, but this debate whether the gut has more bacteria or the skin has more bacteria. We talk about the skin being the largest organ, but what people might not realize is you have these micro-crevices all over your skin with every hair follicle. So at the end of the day, your surface area on the skin is actually massive. Then on the skin, you have micro-communities: You have the organisms that live right on the surface, then ones that live down the hair follicle. And you're right, I think it plays a really important role. Eczema is a clear example where now we're starting to see that you have shifts in the microbiome locally with more staphylococcus aureus. And in fact, some of the studies done by Heidi Kong that were published, looking at how does the microbiome shift with atopic dermatitis, really interesting, not causation, but it's very compelling, it makes you sit back and say, "Hmm, shifts in the microbiome would emerge before the disease would actually emerge." So it makes you wonder, are there early signs that we could try to address so that now we're moving towards preventative medicine or preventative approaches. So I think that's obviously fascinating, and then now they are trying to see if there are ways that you can deliver things topically as a probiotic, either to just control the inflammation or control the staph aureus that's overgrown, and we're going to see a whole new plethora of — I feel like the industry is going to totally have this new avenue of therapeutics that might be very interesting.

Yeah, and I read this — I think it was in a scientific paper, but one of the estimations is: For every skin cell that you have on your skin, you've got about 30 bacteria, right?

Yeah, I totally believe that.

It's like 30:1. For every skin cell that you can see.

I'm just a big bacteria walking around.

Yeah, we're like this crazy walking, talking rainforest, right? All the biomes that matter, the skin biome, the gut biome. But one of the things that it makes me think of is I know that dust for example, in the room or household is 90% skin cells.

Uh-oh, you went there. Every hypochondriac just lost it.

We're going to creep people right out!

Everyone's going to be walking around in space suits!

But think about that, right! If for every skin cell that is sitting on your outer layer, there are 30 microbes, then all of that dust that you see, which is predominantly skin, actually is 30 times more bacteria on there than you can visibly see, dust right? So we're sharing our microbes in large part in a household!

You're making it harder for me to have a reasonable debate with my wife now, because when she says "That mess is your fault!" Now she's going to be like "It's totally your fault! It's all your skin cells, you and your skin!"

Clean up your microbes, will you?

Exactly. Actually, they talk about this microbial cloud that's around you. So if you sit somewhere and you move, that microbial cloud is there for a while, so you're always exchanging clouds like a signature, almost. It's true! We're shedding skin all the time. The dust is everywhere, and they've even shown that if you have a pet, you even diversify the microbes that much more, because they're outside, inside, doing all kinds of things. So there's no qu estion that this whole story about the microbiome is going to shift into microbial clouds and microbial communities at a macro level. It's not just one human anymore, now it's going to be the HumanBiome, trademark, that's going to be amongst the entire family and family biomes and house biomes.

And that's really the crux of what we do, right? We're here exploring these amazing universes that are far more complex than we know. We're on, of course, on the tip of the iceberg of all of this, right? Are there any other known conditions that you can think of that end up becoming shared among people that live together? Like certain skin conditions that I have and I'm shedding my skin and these microbes out there, does that somehow influence someone else within the household?

Well, that's a really good question. I'm trying to think of — there are a couple of conditions that aren't classically thought as infectious. I'll just postulate. There are a couple that I think are interesting: Seborrheic dermatitis for one, malassezia, typically, again, it's not an infection, but an overgrowth of this yeast malassezia, whether it's dandruff on your scalp or if you get scaling on the face or what not. There is this notion that between spouses, especially, when they're sharing the same bed and what not, are you able to transfer yeast between folks, and can that induce dandruff in the other person? Honey, it's not my fault if you have dandruff, again, I just want to make it clear! But there is that possibility. And then the one that's clear-cut, and sometimes this isn't necessarily a microbiome per se, but a macrobiome, but fungal infections, very contagious. So if you have a fungal infection in one child, you'll see this in school age children, many times, if it's like tinea capitis, a fungal infection of the scalp, it'll spread amongst the kids. Another one is molluscum, Molluscum Contagiosum, so there's always a sharing of either warts or molluscum, so it's definitely there. The best of all, chicken pox parties. People might not remember this, but I was so popular as a kid for that one week. It was like, "Oh my God, I'm amazing! I'm so tired, but I'm amazing!" I itched everywhere, and I had all these random kids, and they're like "Yeah, why don't you go play with Raja! Hopefully you'll get chicken pox!" I think I successfully infected a couple of them.

So with that in mind, everything we mentioned is something bad, right? But we could clearly then transfer good stuff to one another? If everyone within the household was really making it a family thing for everyone's biome to be healthy, everyone's diet to be healthy, we could be either — if one person is really focused on being healthy, the unhealthy people could be possibly negating their success, or if everyone does it together, the success will be much more profound, I'm sure, right?

Yeah, there is some evidence, actually, to start thinking about this: So if you look at people that have pets, dogs early, their children have a lesser chance of going on to develop a topic dermatitis, especially if they are exposed to dogs early. I think the reason is that dogs are diversifying the microbiome amongst all the family members and diversifying their skin. Potentially — And we need more studies to really confirm this, but potentially it's because it's helping diversify their skin and bolster them from getting overgrowth of Staph Aureus or whatever it is. So it is very interesting, and oh gosh, tip of the iceberg, right? Who knows what we're going to find, right? I think it's pretty interesting.

But I think that's an important point because we start talking about things that we can transfer that are bad, but the reality is, actually, this sharing that we do all the time is really important for our overall health, right? Like the studies that show that growing up on farms or around things that we might typically think of as dirty…

Oh the hygiene hypothesis.

…yeah, actually have a profound positive impact on us. So we've sort of developed this idea of bacteria are bad, all this is bad, we need to make sure that we sanitize everything with Lysol all the time and we're washing our hands with antibacterial soaps and using these sanitizers, but actually, all of these microorganisms that we're talking about that are on us and around us are not bad and maybe we're not doing such a great thing for our skin and just our microbiome in general by doing that, right?

Yeah, I think it's okay to go out and play in the dirt a little bit as a kid. I think that's a good thing. As a physician, I'm definitely going to wash my hands, you don't want to be spreading that biome, but I think you're absolutely right. I think we need to not be overly clean. I think we are hurting ourselves when we start becoming overly clean. So it's okay if your child is going to go out and play in the dirt a bit or going to go play with other kids. Sometimes, even going to daycare, sometimes they get exposed early to different things, and of course you have to deal with the runny nose and this and that, but you're starting to educate the immune system a bit early, but of course you don't want to go out there and get some really nasty infectious disease, that I understand, but I think it's okay to dirt a bit. Go play in the sandbox.

Yeah, I mean you don't lay down in a public bathroom.

Yeah, exactly but you also don't want to lay down in a bed of soap either. You want to be reasonable about it.

This is all so fascinating, we could talk for several more hours about this, but I know that you have a plane to catch, and so let's wrap up by one of the things that we like to ask people in closing, it's: If there was maybe one idea or strategy, something that our listeners could take an start thinking about or doing today or tomorrow that could make a really positive difference for the health of their microbiome, what would be one of those things?

Your skin is dependent on so many biomes, that a holistic approach has to be a part of a full package. Whether it's the environment or the chemicals, the chemical biome that you put on your skin, or the microbiome or the yeast or the food or the supplements, or the way you think, the mind-body, I think the key is that when you're thinking about skin health and you're thinking about good skin, you really have to fall back on an overall good approach and good lifestyle. That requires really engaging both the internal and the external. It's not enough to just engage the external. And I think as we learn more and more, we'll start to say it's got to be internal, external and existential. So it's got to have that spiritual connection too. And I want to end by saying I think the most powerful player in all this is — it's going to sound a little sappy, but I think having meaningful relationships in your life and having the love biome is going to be super important to put all of this stuff together.

Yup. Fantastic. Really, really wonderful things for people to think about and practical things they can start doing. Thank you so much for being here.

Oh, I loved talking to both of you guys. It's been fun.

Awesome. And thanks to all of you for joining us for today's episode of The Better Biome Podcast. Tune in next week to continue with us as we journey through the universe within.