Treating Adult Acne & Rosacea From The Inside Out

Mark Hyman, MD

Full Transcript

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Dr. Todd LePine: Small intestinal bacterial overgrowth is also one of the triggers for rosacea. A lot of patients that you see with rosacea will have irritable bowel type symptoms or bloating type symptoms. And when you do some testing for that and you treat it, that oftentimes will clear up their rosacea. Dr. Mark Hyman: Welcome to The Doctor's Farmacy. I'm Dr. Mark Hyman. That's Farmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And if you got skin problems, you just listen up because this conversation is going to matter to you, particularly something called rosacea, acne rosacea. It's a terrible skin condition. Let's talk about what it is, but if you have it, you know what I'm talking about and it is miserable. And today we have with us none other than Dr. Todd LePine, who is my colleague, a frequent guest here on the special episode of The Doctor's Farmacy, the house call episode. He's a graduate Dartmouth medical school. He's board certified in internal medicine. We've worked together for decades. Now it's almost three decades. It's kind of scary. Holy cow. You don't look any different than the day I met you. So functional medicine must be working. He is an incredible guy and he teaches all over the world. Well, not so much anymore, but virtually now- Dr. Todd LePine: Virtually. Dr. Mark Hyman: And is part of the faculty in the Institute for Functional Medicine, American College for Advancement in Medicine, Age Management Medicine, and many, many other great, great organizations. So Todd, welcome back to The Doctor's Farmacy. Dr. Todd LePine: Thank you, Mark. Dr. Mark Hyman: Okay. So first of all, we're talking about this weird condition that some people never heard of called acne rosacea. We're going to talk about what it is, how traditional medicine deals with it, why that's all wrong and how we approach it using functional medicine. So what is acne rosacea? Dr. Todd LePine: Sure. Okay. Well, acne rosacea is a chronic inflammatory condition that adults get. It's also another name for it is a adult acne and patients who have it will get redness to the face, usually over the cheeks and the nose, sometimes the chin. And it can also be pretty severe. You can get telangiectasias, which are like little blood vessels- Dr. Mark Hyman: Those little bloodline [crosstalk 00:01:59]. Dr. Todd LePine: Vasodilation of the blood vessels, papules, pustules. So it looks like adult acne is really what it is. And interestingly, it's fairly common. About 10% of the population has it. It tends to be more common in people who have Celtic origin. So Irish, Scottish, English, which is interesting. I'll talk about that later. Dr. Mark Hyman: So I'm Jewish from the Middle East. I'm safe. Dr. Todd LePine: Yeah. You might be. Absolutely. It might be. It might be. Yeah. And a lot of famous people have actually had this. Bill Clinton is one. W.C. Fields. Dr. Mark Hyman: That big bulbous nose. Dr. Todd LePine: Exactly. Dr. Mark Hyman: That's an extreme version of it. Dr. Todd LePine: So yeah. So one of the complications of rosacea is chronic inflammatory changes to the skin. So you can get what's called rhinophyma, which is basically when you see a clown with a red nose, that's rhinophyma. Dr. Mark Hyman: Yeah. Dr. Todd LePine: That's what rhinophyma is. Dr. Mark Hyman: Big red nose. Dr. Todd LePine: And it can be actually quite debilitating. I mean, when it gets really, really bad, you can get this distortion of the facial features, especially over the nose. Yeah. Dr. Mark Hyman: Yeah. So it's this really nasty kind of acne and what's what triggers it? Do we know from a traditional medicine point of view? Dr. Todd LePine: There are a variety of different triggers. When people have rosacea things that can trigger it are spicy foods. Alcohol can do it. Dr. Mark Hyman: Alcoholics tend to get this a lot, right? If you're an alcoholic, and W.C. Fields clearly was. Those of you who don't know who he is, Google it. It's probably before your time, but it is often driven by alcohol. Dr. Todd LePine: Yeah. And my own theory on alcohol, as it ties in with that, is that alcohol does vasodilate blood vessels, but also alcohol in excess is also a big contributor to leaky gut. And I get my patients to understand this concept that alcohol can promote leaky gut. So if I took a shot of tequila and I threw it in your eye, what would happen? Dr. Mark Hyman: It would burn. Dr. Todd LePine: Your eye would water. Right? You're liable to get leaky. You got a leaky eye, leaky gut. So chronic alcohol ingestion is probably one of the biggest things for low grade endotoxin and leaky gut. And that's also tied in, as we'll talk about in terms of irritable bowel and- Dr. Mark Hyman: Yeah. We're going to get into leaky gut because that it's a very big issue in general and particularly with things like skin disorders like acne rosacea. Dr. Todd LePine: Yeah. Yeah. Dr. Mark Hyman: So, Todd, in functional medicine, we take a very different view, which is we treat things from the inside out, not the outside in, right? And dermatology is all about lotions, potions and creams and slathering stuff on your face to sort of get it good from the outside in, but it's kind of backwards. Dr. Todd LePine: Yeah. Dr. Mark Hyman: So what are the traditional treatments for rosacea and why are they not the best idea? Dr. Todd LePine: When I went through my medical training, there was an old saying that the dermatologist, basically, if it's dry, wet it, if it's wet, moisturize it and if you don't know what's going on, give it a steroid. Dr. Mark Hyman: That's pretty much right. That's pretty much dermatology. I learned the same lesson. Dr. Todd LePine: Right. That's it. And dermatology- Dr. Mark Hyman: If it's wet, dry it, if it's dry, wet it and if you don't know, give it a steroid. Dr. Todd LePine: Exactly. That's the mantra of the modern dermatologist. But again, like you said, it's an external manifestation of something going on internally. So the question is, is what's driving this and in preparing for this talk, I mean, I've seen so many patients with rosacea, it's not funny. Dr. Mark Hyman: What do they put on there? They give antibiotics on the face. Dr. Todd LePine: They'll give like metronidazole cream, which is a topical antibiotic. Dr. Mark Hyman: It's like an anti-parasite antibiotic. Dr. Todd LePine: One of the newer medications, and this is sort of an interesting thing, is a cream called ivermectin. So this sort of blew me away because this is relatively new. And I think we were talking about earlier. Dr. Mark Hyman: It's a worm pill. Dr. Todd LePine: It's a parasite- Dr. Mark Hyman: They're using it for COVID even. Dr. Todd LePine: Really? Dr. Mark Hyman: Yeah. Dr. Todd LePine: Yeah. So I was reading and I actually had a patient who came in and was on the ivermectin cream and was doing very, very well on the ivermectin cream. And then I said to myself, "Well, how is an anti-parasitic medication topically helping with rosacea?" Dr. Mark Hyman: You got worms in your face? Dr. Todd LePine: Yeah, well, that's also interesting because one of the things that is strongly tied in with rosacea, and now remember rosacea is just over the face. It's this facial manifestation of an internal issue is that we have these little creepy crawlers on our face and they're called mites, skin mites. Dr. Mark Hyman: Yeah. Dr. Todd LePine: Demodex. Dr. Mark Hyman: Kind of like dust mites, but they're on your- Dr. Todd LePine: We all have them. Everybody has these. And the interesting thing is that patients who have rosacea have a much, much higher density of skin mites on them for whatever reason. And normally they basically, they're like little, I call them like little parasites, they're ecto parasites and they sit on the skin and they eat your dead tissues and they eat off of the oils on the glands. And normally you don't have a reaction to them. They're sort of like a benign parasite, but in some people who have high concentrations of these skin mites, the body makes a very, very high immune response to it. So getting back to the ivermectin, which is basically an antiparasitic, it may be actually working as an antiparasitic for some of these skin mites. Dr. Mark Hyman: Yeah. So maybe there's an infectious cause to this. The things they use are minocycline, which is an antibiotic, Flagyl or metronidazole, always is an anti-parasite antibiotic, ivermectin, which is an anti-worm pill. Dr. Todd LePine: Oral doxycycline is another one. Dr. Mark Hyman: Yeah. We're all antibiotics, which probably is a really bad idea given the fact that you have a microbiome and you don't want to be killing it to fix your skin. Right? Dr. Todd LePine: Exactly. Exactly. Yeah. Dr. Mark Hyman: And why might that minocycline work? Why might antibiotics orally work? Dr. Todd LePine: Well, there's a thought and it's actually in the literature, is that small intestinal bacterial overgrowth is also one of the triggers for rosacea. A lot of patients that you see with rosacea will have irritable bowel type symptoms or bloating type symptoms and when you do some testing for that and you treat it, that oftentimes will clear up their rosacea. Dr. Mark Hyman: Yeah. Dr. Todd LePine: Yeah. Dr. Mark Hyman: Absolutely. So I think we're not adverse to using topicals and topical medication when necessary, but if you really focus on root causes, which is what functional medicine does, you come up with a very different set of approaches that actually works better, is longer lasting and doesn't require you to keep putting on lotions, potions, and creams for the rest of your life or taking oral antibiotics. Dr. Todd LePine: Right. Exactly. And then getting back to the ivermectin, ivermectin, in preparing for this talk, I did a little bit of research and the patients who are more prone towards rosacea have a problem with too much of what's called the cathelicidin antimicrobial peptides. So these are- Dr. Mark Hyman: That's a big mouthful. Dr. Todd LePine: Yeah. They're called CAMPs, C-A-M-P, cathelicidin antimicrobial peptides. And these peptides are part of the built-in innate part of the immune system to protect our skin against various types of infections. And it turns out that ivermectin actually helps with these antimicrobial peptides because people who have rosacea have too much of these peptides. They have an over robust response to antimicrobials. So it's thought that the, it's actually a breakdown product, it's called LL-37 and ivermectin actually works on dampening down these anti-microbial peptides to decrease inflammation in the skin. Dr. Mark Hyman: Okay. So in terms of the cause, it seems to be a combination of internal and external factors, right? Dr. Todd LePine: Yeah. Dr. Mark Hyman: Something on the skin and then some things internally, but from traditional medicine, there really isn't an approach to helping heal the skin from the inside out. Dr. Todd LePine: No. Dr. Mark Hyman: And whether you have acne or eczema or psoriasis or rosacea or any one of the myriad skin conditions that we get, most of them have their root cause inside, not on the topical level. Dr. Todd LePine: Exactly. Dr. Mark Hyman: And often it's the gut. Dr. Todd LePine: Yeah. Absolutely. Yeah. Dr. Mark Hyman: So you mentioned a little bit earlier leaky gut. So take us through from a functional medicine perspective, our thinking about the root causes. What are the things that you think about when someone comes into your office and their face is all red and they got all this acne on there, and they've got all these telangiectasias, these little red lines everywhere, and you can see the blood vessels dilated and they're kind of looking like Santa Claus? Dr. Todd LePine: Yeah. Yeah. Exactly. Yeah. And they also get photosensitivity too, which is the other thing. And the interesting thing is- Dr. Mark Hyman: They can't go in the sun without getting worse. Dr. Todd LePine: And that also ties in with these antimicrobial peptides, because it's thought, it's theorized that the Celts, the ones who live in the higher northern latitudes, they don't get as much sun as we do. So it's thought that from an evolutionary standpoint, that they benefit by having this. They have a more robust immune system when there's not enough sunshine and sunshine will actually activate this innate immune system. And that's why sun exposure oftentimes makes it worse because they produce more of these antimicrobial peptides. And then those antimicrobial peptides have to get processed. And in the process of breaking them apart, the immune system then starts responding to it. So that's why there's a sort of a photosensitivity aspect to it. Dr. Mark Hyman: And what are the other sort of things you think about when someone comes to your office with rosacea? Dr. Todd LePine: Well, one of the things I oftentimes look at is their vitamin D levels. Vitamin D is part of the immune system. And it's tied in intimately with the antimicrobial peptide system in the body, so oftentimes patients who have this have low vitamin D levels. We'll look at the microbiome testing to see if there's any evidence of dysbiosis, bacterial overgrowth testing, the SIBO testing, checking for hydrogen and methane. I mean, probably the majority of patients who I see have rosacea have problems with bacterial overgrowth. Other thing is low stomach acid, which also promotes and contributes to bacterial overgrowth. So checking for the patients, sometimes these patients are also on PPIs. Dr. Mark Hyman: Acid blocking medications. Dr. Todd LePine: Acid blocking medications. Absolutely. Yep. Dr. Mark Hyman: Yeah. Dr. Todd LePine: Because we have acid in our stomach to help us to digest food. It's also there to decrease the amount of bacteria higher up in the colon. So it's good to have stomach acid. Dr. Mark Hyman: Yeah, because if you don't have stomach acid, then the pH of your small intestine changes, becomes more alkaline and then bugs grow in there that wouldn't necessarily grow. And that's when you get this overgrowth of bad bugs in there. And it can be what causes SIBO, which is small intestinal bacterial overgrowth, where bad bugs migrate up from the lower intestine into the small intestine. And then when you eat foods, you get bloating, distension. It causes leaky gut. You ended up causing damage to the lining of the gut and food particles and bacterial toxins leak in and create inflammation throughout the body and on the skin. So leaky gut can cause hundreds of different manifestations, one of which is rosacea. And unless you think about that and learn how to treat it, you may not be able to be successful with it. There's also another condition that I've seen, Todd, in a lot of my patients called SIFO, SIFO. Dr. Todd LePine: Small intestinal fungal. Dr. Mark Hyman: Small intestinal fungal overgrowth. And a lot of people talk about it as candida, but there's many, many species of yeast and fungus. And so what I've found often is that treating the gut through addressing the bacterial overgrowth, the yeast overgrowth, healing leaky gut, dealing with the food sensitivities makes a profound impact. Dr. Todd LePine: Yeah. Dr. Mark Hyman: And a lot of times it is food sensitivities that can trigger it. I mean, for example, gluten, we've talked about it on the show, that is one of the biggest drivers of leaky gut. And even if you are not celiac, and even if you don't think you have any symptoms or don't notice any symptoms when you eat gluten, Dr. Alessio Fasano, who's the world's expert at Harvard on gluten, he said everybody who eats gluten creates some level of leaky gut and most people kind of handle it. Dr. Todd LePine: Right. Transient leaky gut. Exactly. Dr. Mark Hyman: Yeah. So, I don't know. It's probably not a good idea to eat that much gluten because of the potential to create leaky gut and how that is linked to so many chronic diseases, including weight gain, diabetes, cancer, heart disease, Alzheimer's, autoimmune diseases, allergies, acne. I mean, he was naming depression, all of this stuff is connected by leaky gut. So I really, I think, getting a very different thinking about this is key. And you did, you talked about the stomach acid, you talked about the acid blockers. You talked about maybe other things that are relevant in the gut and certain infections like H. pylori, which is a common bacteria that causes ulcers, also has been linked to H. pylori and food sensitivities. Dr. Mark Hyman: Hey everybody, it's Dr. Hyman, thanks for tuning into The Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you to all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter, and in it, I share my favorite stuff from foods to supplements to gadgets to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else I promise. And all you do is go to longevityfilm.com/picks to sign up. That's longevityfilm.com/picks, P-I-C-K-S, and sign up for the newsletter and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer. Now, back to this week's episode. Dr. Mark Hyman: So how do we approach these patients when they come in? What are the kinds of things that we would do from a diagnostic point of view that you wouldn't get when you went to the dermatologist? Dr. Todd LePine: Well, from a diagnostic standpoint, again, I would do testing for leaky gut. I would do intestinal permeability testing, checking for antibodies to zonulin with the Cyrex testing that we do, Cyrex array number three. Dr. Mark Hyman: So that's basically, there's a test that we do at the center, The UltraWellness Center here in Lenox, Massachusetts, where we're recording live, is a Cyrex testing. It's a lab that looks at antibodies that you produce against these proteins that are in your gut that come from gluten or even from bacteria. And so if you're creating a lot of antibodies to these proteins, it's clear that they're getting across the lining of your gut, leaking into your bloodstream and causing an immune response, which is not only local, but systemic. Dr. Todd LePine: Right. And there are other ways you can actually measure zonulin in the blood and you can measure it also in the stool. And that's only like a snapshot in time. So you can develop leaky gut for a couple hours or a day or so, but if it stops, then you're fine. The antibodies against zonulin is the one that tells you that there's this chronic leaky gut, which is really more valuable because if I gave you a shot of tequila, then an hour later measure your zonulin, it's going to go up. Dr. Mark Hyman: Okay, where's the tequila? Dr. Todd LePine: Right. So that's why I think that the testing for the antibodies against zonulin is even more valuable in these patients with chronic conditions. Dr. Mark Hyman: And then what other kinds of tests besides the zonulin and the lipopolysaccharide tests that we do to look at the antibodies against these proteins in the gut that come from a leaky gut? Dr. Todd LePine: We'll do the small intestinal bacteria overgrowth, where we will measure the production of fermentation products. So hydrogen and methane are gases that are normally produced in the body. When people have small intestinal bacterial overgrowth, those will be produced at higher levels. So we can check that and over time, I think we are the tests that we do is a three-hour test, so you measure baseline hydrogen methane, check it at intervals of about every half hour. And you do that over a three hour time period and that can tell you definitively do you or do you not have bacterial overgrowth and how bad is it? And is it predominantly hydrogen or is it methane? Dr. Mark Hyman: So essentially what you're saying is that when we eat foods, humans don't produce gas. It's the bacteria that are fermenting the foods we eat that produce the gas. So you feel bloated or distended or you're passing gas, it's not you. You can blame it on the bugs. But problem is that we don't know how to regulate the bugs and get a healthier ecosystem. Dr. Todd LePine: Right. Dr. Mark Hyman: And that is what most physicians never were trained to do and it's the foundation of functional medicine. It's the foundation of our practice here at The UltraWellness Center, where we really dig into these issues and we look at bacterial overgrowth. We look at fungal overgrowth, we look at leaky gut, we look at food sensitivities. We'll do other testing to look at whether you're reacting to gluten or dairy or eggs or other foods. And it's really helpful in drilling down on what's really going on with people. Dr. Todd LePine: Absolutely. Yeah. And we're talking basically producing gases, that's basically a fermentation process and normally fermentation happens lower in the colon, in the colonic area. It's more of an anaerobic environment or a lack of oxygen. That's normal for that to be happening. But when that process is taking place higher up in a different neighborhood, it's not a good thing. Dr. Mark Hyman: Yeah. And I mean, you want your upper intestine to be sterile. Dr. Todd LePine: Or mostly sterile. Dr. Mark Hyman: Mostly sterile and when all that bacteria migrates up there, it's just a bad situation. And when we take acid blockers, when we are low in magnesium, which half of us are, when we're under stress and our gut motility is slow, when we have taken lots of antibiotics and it screws up our whole system in there, all of these are reasons why we get these bacterial overgrowth issues and they're super common and they're relatively easy to treat with functional medicine. Now, the other thing we do is look at stool testing, right? So we look at not just the proteins from leaky gut or we look at the food sensitivities or bacterial overgrowth, gas production, but we actually look at the poop. So what are we looking for in the poop that helps us figure out what's going on? Dr. Todd LePine: Well, there's a lot of things. There's gold in there. There really is. Dr. Mark Hyman: Gold in them there hills. Dr. Todd LePine: Gold in them there hills. Yeah. So a lot of information can be determined by doing a microbial analysis. So you can look at the overall balance of bacteria. So everybody's got hundreds of different kinds of bacteria in the GI tract. And we can measure those using DNA PCR analysis and we can do quantitative. We can measure how many there are of each different species, look at ones that are normally found, look at ones that are found in the gut. But normally they want to be at low levels. Look at bacteria that are associated with autoimmunity, so things like Citrobacter, Klebsiella, salmonella, et cetera. We can look at now analyze for yeast overgrowth, forms of yeast. And then also microbial markers of inflammation, things like calprotectin. looking for fat. So you can get a- Dr. Mark Hyman: Enzyme function. Dr. Todd LePine: Enzyme function, butyrate, checking for butyrate- Dr. Mark Hyman: Short chain- Dr. Todd LePine: Short chain fatty acids. Dr. Mark Hyman: Indicators of healthy ecosystem. So, Todd, what you're saying is in traditional sort of microbiome testing, they just look at the genetic material of the microbiome and they can't really test everything, although they can do some really extraordinary tests now, but there are kits out there where you can look at your microbiome, but it's far more than just what bugs you have in there. It's what they're doing. And so we look at the result, the function on the ecosystem, we look at, like you said, the enzyme functioning, absorbing your food. Is there inflammation? Are you having good bugs in there that are producing the super fuel for the gut, these short chain fatty acids that are so important- Dr. Todd LePine: Oh, huge. Dr. Mark Hyman: Looking for the right balance. Are you missing some key bugs? You have overgrowth of bad bugs. You have yeast. You have parasites. And it's such a much more comprehensive stool test that we do here at the UltraWellness Center. Dr. Todd LePine: We were talking earlier about delta sleep and the interesting thing is, is that when you have good bugs in the digestive track and you're eating enough fiber in your diet, and you're producing high levels of butyrate, that has an effect on the brain and also improves sleep. Dr. Mark Hyman: That's amazing. Dr. Todd LePine: Yeah. Yeah. Dr. Mark Hyman: So you have to get your poop together to sleep better. I got it. Okay. That's a good strategy. Better than taking Ambien. Dr. Todd LePine: Yeah. Dr. Mark Hyman: All right. So we also look at other things like omega-3 fats and other fats, because a lot of inflammation come from not having the right balance of fats in your body. And I think, so when you have a patient come in, what are the steps you would take initially to treat a patient with rosacea from a functional medicine perspective? Dr. Todd LePine: Taking the history is the big one. I always will ask people, "What's your ethnic background?" A lot of people say, "I'm white." No, it's like, "Are you Irish, English, German, Jewish, Russian, whatever?" Because the rosacea is typically found in light skinned, fair-skinned people. And from a genetic standpoint, they are the ones who are more likely to have that. It's just an interesting part to have in terms of the history. And then I'll just ask them, "What is it you're eating? Are you eating a standard American diet? How much alcohol are you drinking? How much stress do you have?" Stress also- Dr. Mark Hyman: Caffeine. Dr. Todd LePine: Yeah. Caffeine can play a role. Dr. Mark Hyman: Spicy foods can trigger. Dr. Todd LePine: Those are all things which can sort of, it's like adding gasoline to the fire because literally rosacea is the skin on fire in the facial area, but doing the testing for essential fatty acids, making sure that they have the right balance of the essential fats in their diet. A lot of people have too much omega-6, which tends to be more pro-inflammatory, lack of the omega-3s. One of the oils, I don't know if you've used it, that I've found very helpful with patients who have rosacea is borage oil and evening primrose oil. They tend to be very, they help to dampen down that inflammatory response. Dr. Mark Hyman: And that's a very key omega-6 that people don't think about much, but it's called gamma linolenic acid, which is a very powerful anti-inflammatory. It's not like the omega-3s, but it's sort of like the omega-3s, but on the omega-6 side. Dr. Todd LePine: Exactly. Dr. Mark Hyman: And it something we really have a hard time getting in our diet. It's in like borage oil and a few other things, but evening primrose oil. So yeah, that's very powerful. I agree. And I also think that when I see these patients, I also think about looking for other clues, like do they have yeast issues? Have they been in lots of antibiotics? Are they on acid blockers which caused yeast overgrowth? Dr. Todd LePine: Yeah. Dr. Mark Hyman: Do they have other fungal issues? They have dandruff? Do they have anal itching? Do they have thrush or a white coating in their tongue? Do they have vaginal yeast infections? Do they have other skin markers of yeast like little tinea or other kinds of things? So you'll see often a pattern of other issues around fungal stuff. I'll check for H. Pylori. I'll check again, all the tests we did talk about and see what's really going on. And then, from the treatment point of view, you start with an elimination diet, with an anti-inflammatory diet. Dr. Todd LePine: Exactly. Yeah. Putting patients on an anti-inflammatory elimination diet, 80% of the time doesn't matter what they come in with, they'll actually get better. Getting them off of the pro-inflammatory foods and then putting in foods which are anti-inflammatory, cold water fish, sardines, wild salmon, the essential oils, like evening primrose oil, help to sort of dampen down that inflammatory response. Dr. Mark Hyman: Yeah. I agree. I think we don't understand, most of us, how powerful food is as medicine and how it can drive tremendous amounts of inflammation throughout the body. And obviously if it's on your skin, it's visible, but there's also invisible inflammation that you're not seeing that's driving all the chronic diseases. Dr. Todd LePine: And you actually just triggered a thought because there's actually a paper that says, if you have rosacea, you have a higher incidence of Alzheimer's disease. Dr. Mark Hyman: Oh, wow. Dr. Todd LePine: So it's not just a cosmetic issue. It's actually a systemic inflammation. Dr. Mark Hyman: So you have a red face and a red brain that's on fire. Dr. Todd LePine: Exactly. Yeah. I was sort of blown away by that. Dr. Mark Hyman: That's fascinating. Dr. Todd LePine: Yeah. Especially in women. It's actually more common in women. Dr. Mark Hyman: So, you advise people the obvious things, cut out the alcohol, the caffeine, stay away from the sun, stay away from spicy foods. We also tell them stay away from gluten, which triggers leaky gut. Often dairy. You actually add in all the anti-inflammatory foods that are important, all the phytochemicals from plant foods and turmeric and ginger and garlic and rosemary and all these powerful foods that can really help to reduce inflammation. And then we often directly treat the issues that are going on. It could be leaky gut. So we give them a gut repair program. This could be fungal or bacterial overgrowth. So we'll take care of those with either herbs or antibiotics or antifungals. And you'll see these patients really dramatically improve when they change their diet and they resort their gut and then sometimes we'll use like things like evening primrose oil. I found that digestive enzymes and hydrochloric acid often are really helpful too. Dr. Todd LePine: So I've been surprised at how many people have what I would call a relative lack of hydrochloric acid in the stomach. I'd venture to say that the majority of people don't have too much acid, they have not enough in the stomach. Dr. Mark Hyman: Yeah. Well, that's interesting because the third leading category of drugs are the acid blockers like Prilosec and Prevacid and Pepsid and all these other drugs, these Nexium, [masofex 00:26:56]. I mean, they're just like out there everywhere. And now they're over the counter and anybody's- Dr. Todd LePine: Yeah, exactly. Dr. Mark Hyman: I mean, we've talked about this before on the podcast, but when I was in medical school, the drug reps came in because these drugs had just come out and they're like, "Listen guys, these drugs work. They're great. They will help people with ulcers if they're really bad. You don't want to keep anybody on it for more than six weeks." Dr. Todd LePine: Right. That's a huge [crosstalk 00:27:18]. Dr. Mark Hyman: "Stomach acid. It's really bad long-term." These are the drug reps telling us this. And now it's like, people are on it for decades and it causes B12 deficiency, magnesium deficiency, zinc deficiency. Dr. Todd LePine: Osteoporosis. Dr. Mark Hyman: Osteoporosis, pneumonia, bacterial overgrowth, irritable bowel syndrome. You get rid of your heartburn, but you got all these other problems. And then it's one of those drugs it's so sneaky because it's addictive. Once you get on it, it's hard to get off it because it causes this rebound. Dr. Todd LePine: Absolutely. Dr. Mark Hyman: So when you suppress the stomach acid and you stop the drug, that acid production goes crazy, which makes you feel horrible. And then you go, "I need the drug," but you can actually taper it down and use other strategies to help people get off of it. Dr. Todd LePine: And you bring up a really good point because a lot of the pharmaceutical medications, especially some of the psychotropics, so the antidepressants, are like that too. The PPIs and the antidepressants, when you try to get off of them, you get this rebound process. So the body tries to get back into balance and it can be very difficult. So you've got to go low and slow when you're trying to taper off the PPIs or taper off antidepressant psychotropic meds. Absolutely. Dr. Mark Hyman: Amazing. So what cases have you recalled about rosacea that you want to share that gave you a sense of this? Dr. Todd LePine: Yeah. Well, I had a patient who came in and she was a undiagnosed celiac, not just a gluten sensitivity, she was an undiagnosed celiac. She was Irish. And she was having a standard American diet. And she was self-medicating for her heartburn with over-the-counter acid blocking medications. Had a lot of bloating type symptoms and came in and her major complaint was her skin, but she had all these other things, but her big thing was how I look. Right? So people are vain and- Dr. Mark Hyman: Gets people's attention. Dr. Todd LePine: Exactly. Right. And then when I did a dive into her testing, it turned out that she was deficient in her essential fatty acids, especially the gamma linolenic acid. She had a lack of stomach acid because of the PPIs. You can actually measure a test, a blood test, a commercially available test called gastrin and gastrin levels will go up when you block acid. So that's actually one of the tests that I actually like to use when I have patients who I'm trying to get them off of a PPI, because the higher the gastrin level, the more difficult it will be to get off the PPI. And that's sort of, it'll tell you how easy you can get off- Dr. Mark Hyman: These acid blockers, that's the PPI, right? Dr. Todd LePine: Exactly. And then she also had low vitamin D levels. I mean, we spend a lot of our time clothed and indoors, so we don't get way enough sunshine. That's one of the big things and low vitamin D. You don't just fix low vitamin D. This is one of my, I get up on my soap box all the time with here is you don't just fix low vitamin D by taking vitamin D. Vitamin D deficiency is basically a sunshine deficiency. There are certain times when there can be other causes, like you might have fat malabsorption that can cause low vitamin D or you may have problems with synthesis because of lack of skin oils when you get exposed to the sun, but by and large, low vitamin D levels is related to sunshine deficiency. And low vitamin D is not the problem. It's a symptom of another problem. And the immune system is also benefited by sunshine exposure, healthy sunshine. Dr. Todd LePine: I think you said you enjoy going to the tropics now and then, Caribbean, Hawaii, whatever. And we also feel good. It's also, this is another thing that I find fascinating is that there is a condition which is called sunshine addiction, these people who are suntan addicts. Well, it turns out that our bodies actually produce endorphins when we are exposed to the sun. So there's a feedback mechanism. Dr. Mark Hyman: That's incredible. Dr. Todd LePine: There's a compound is called a pro-opiomelano corticotropin hormone. And what it means is that our bodies give a reward when we're in the sun. So we feel good. We have these feel good molecules, these endorphins, that make us want to get the sun. Dr. Mark Hyman: Oh, that's interesting. That's why I love going in the sun. Dr. Todd LePine: Exactly. And then there are these people who- Dr. Mark Hyman: I always feel so good when I go to the beach in the summer. It just makes me so happy. Dr. Todd LePine: Exactly. And the interesting is actually, you can get addicted to the sun and that's like you can get addicted to food. I mean, your body needs food to survive and your body actually needs sunshine to survive. So nature has built in these feedback mechanisms so that it encourages us to do it. Dr. Mark Hyman: That's incredible. Dr. Todd LePine: Yeah. Isn't that wild? Dr. Mark Hyman: So what happened with this patient? What did you do for her? Dr. Todd LePine: Well, I did a lot. I mean, I had her work with our nutritionist and got her off of her standard American diet. I treated her bacterial overgrowth. She had a significant SIBO test. So I treated that primarily with herbs. A lot of people will use antibiotics, things like rifaximin or Xifaxan for SIBO. I actually find that I do just as well using anti-microbial herb preparations. I supported her stomach acid using betaine HCl. Some patients don't respond to that. They don't tolerate it as well, so sometimes I'll use things like apple cider vinegar, and then got her fatty acids up, gave her a little bit of borage oil and a combination of that. And then also just told her to get some healthy sunshine. It doesn't necessarily mean that you need to go out and sunbathe or go to a suntanning booth, but just getting healthy sunshine can help with down-regulating the immune system. Dr. Mark Hyman: Yeah. Dr. Todd LePine: And interestingly, just off topic, but with COVID there some really interesting studies that giving high dose vitamin D helps with COVID infections. Dr. Mark Hyman: Absolutely. Dr. Todd LePine: And so COVID actually, or vitamin D, when it's at high enough levels, actually helps to keep the immune system in balance. It keeps it from [crosstalk 00:33:16]. Dr. Mark Hyman: Yeah. It controls hundreds of genes that regulate immunity and inflammation. It's pretty amazing. It's not really a vitamin. It's more like a hormone. Dr. Todd LePine: Exactly. Exactly. It's like a hormone and it's also actually acts like a steroid too. It's a cholesterol molecule moiety. And I oftentimes, if I'm coming down with a cold or flu, I'll up my dose of vitamin D, especially in the winter, absolutely. Dr. Mark Hyman: It's true. When I feel like something's coming on, I take like 50,000 units for three or four days and I never get sick. It literally goes away by the next morning. Dr. Todd LePine: It is. It's pretty powerful. Dr. Mark Hyman: So Todd, we've just covered a lot here. And I recall a lot of cases of mine that have had rosacea, and it's always one of those things where I love seeing because so easy to treat and people suffer so much from it. And just by following the functional medicine approach, looking at the root causes, treating the skin from the inside out, addressing the gut, addressing food sensitivities, addressing nutritional deficiencies, which is really the foundations of functional medicine, these people get better and we don't just take it at face value. Pun intended. We actually go under the hood and look at what's going on. I think there was one great quote I heard somewhere that traditional medicine is like trying to diagnose what's wrong with your car by listening to the noises it makes instead of looking under the hood and functional medicines about looking under the hood. Dr. Todd LePine: Absolutely. Dr. Mark Hyman: And here at the UltraWellness Center in Lenox, Massachusetts, we've been doing this for decades. We have the most incredible team here who collectively have probably 70 years of clinical experience in functional medicine. And we're doing most of our care virtually now. So wherever you live in the world, we can take care of your using virtual Zoom consults. And it's pretty gratifying to see how many people are taking advantage of that and getting better. And I think that this is a challenging moment for everybody. And I think we often neglect our own health and our own healthcare. Nobody wants to go to the doctor. Nobody wants to go to the hospital anymore, but I think people can get virtual care now, which is super awesome, and we invite you to check it out. You go to ultrawellnesscenter.com. If you're suffering from any skin disorder, whether it's acne or acne rosacea or eczema or psoriasis, we've had some podcasts on that. Go listen to them. But this is really an approach that works for skin disorders. I love skin problems because they are so easy to treat whether, like I said, it's eczema, acne rosacea, whatever it is, it's pretty striking. And it's just heartbreaking to see how many patients struggle with these conditions because they're often so embarrassing. It's one thing if you have bacterial overgrowth and bloating, you're the only one that knows your stomach's bloated. Right? But if you've got this nasty looking face or skin issues, you don't want to be seen like that. And I think it affects people's sense of wellbeing and their self worth. Dr. Todd LePine: Absolutely. Dr. Mark Hyman: And I just want to point out there is really clear approaches that help this get better. Dr. Todd LePine: Yeah. And the exciting thing is is it's a lot of the conferences that I go to, there are now functional medicine dermatologists who get it, because most dermatologists do not realize or remember that the skin and the gut are contiguous. They are connected. So when you have a skin problem, it's oftentimes an internal problem and the functional medicine dermatologists, which are growing, are getting that and they're really helping people. Dr. Mark Hyman: Yeah. I agree. It is one of the most exciting parts of functional medicine is dermatology because it's such a slam dunk. Dr. Todd LePine: Yeah. Dr. Mark Hyman: And there are a number of really great functional medicine doctors out there who are dermatologists and the stories are amazing. I just see so many people suffer unnecessarily. Dr. Todd LePine: Unnecessarily. Exactly. Dr. Mark Hyman: Yeah. So if you've been loving this podcast and you know someone with a skin problem or you've got a skin problem, come see us here, share with your friends and family on social media, leave a comment. We'd love to hear how you've addressed your skin issues, what's worked, what hasn't worked. Subscribe wherever you get your podcasts. And we'll see you next time on The Doctor's Farmacy.