Episode 24: Dr. Julie Greenberg, ND on Holistic Skincare for Acne, Eczema & Psoriasis

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SPEAKERS: Dr. Andrew Wong, Dr. Julie Greenberg

Welcome to the Capital Integrative Health podcast, a podcast dedicated to transforming the consciousness around what it means to be healthy and understanding the root causes of both disease and wellness. I am Dr. Andrew Wong, co-founder of Capital Integrative Health, an integrative practice committed to expanding access to holistic root cause medicine to the global community.

Dr. Greenberg:

Lotion is a combination of oil and water. Well, what happens when we put oil and water together? I think we all did this science experiment in fifth grade and we see that they don’t mix, they float and they are completely separate so how do companies get a lotion? Well, they have to use a chemical called an emulsifier to smash together the water and oil at the molecular level and keep them there so now we’ve got a ton of emulsifier and now that we have water in the product, you have to have preservatives. There’s no option. So, when you use a lotion as a moisturizer, you’ve got oil, water, emulsifier, preservative. Emulsifier and preservative, that whole class of chemicals are going to be the ones that tend to fire up red on that type of EWG working database. They are not natural, they are not good for your skin, they are not good for you.

Dr. Wong:

Have you ever wondered what you’re really putting on your skin? Before you put on that moisturizer next time that is actually harming your skin, you need to listen to this. Today, we’re jumping into the world of skin care and holistic approaches to healthy skin with Dr. Julie Greenberg. Dr. Greenberg is a licensed naturopathic doctor and registered herbalist who specializes in integrative dermatology.

I am Dr. Andrew Wong, co-founder of capital integrative health. This podcast is dedicated to transforming the consciousness around what it means to be healthy and also exploring and understanding the root causes of both disease and wellness. And today, we’re going to take a deep dive into skin health. Our conversation with Dr. Greenberg was a great conversation into how our skin is connected to our whole health and what we can do to heal our skin. Dr. Greenberg is passionate about natural skin care and believes that many of today’s chronic skin diseases and conditions can be healed by using evidence-based alternative treatments. So, if you’re suffering from skin conditions like acne or eczema or psoriasis, this is a conversation for you or if you’re just ready for healthy skin, this is also a conversation that’s a must listen. Well, thank you Dr. Greenberg for being on the podcast today and such a pleasure to have you on today.

Dr. Greenberg:

Thanks so much for having me, Dr. Wong. It’s a pleasure to be here.

Dr. Wong:

So, as an integrative dermatologist and naturopathic doctor and integrative dermatologist, can you explain to all of us what the connection is between the gut and the skin?

Dr. Greenberg:

Yeah. So, first off, let me say that I tell patients and prospective patients that I’m a naturopathic doctor who specializes in dermatology. I don’t call myself a dermatologist because I think that implies four years of medical school as an MD and then ongoing training for residency so I’m not a dermatologist in that sense but I am a naturopathic doctor who specializes in dermatology meaning, I only see patients with dermatological complaints and your first question just hits the nail on the head because the main way that I go about addressing the root cause of chronic skin conditions and hair things like alopecia areata is to go for the gut. There is a very intimate connection between the gut and skin. Of course, we have a whole microbiome on the skin and a whole different microbiome in the gut and they are very different but there’s crosstalk in between all of our systems and all of our microbiomes and they influence one another so if we think about how the human is structured, right, the outside is our skin. It’s made of a tissue called epithelial tissue. The inside, we’ve got the whole GI tract also made of epithelial tissue and the bridge is the mouth so there’s a lot of crosstalk that’s going to happen between the skin via the mouth and through the gut but also through the gut. I mean the

whole point of eating is to absorb nutrients so things get from the gut into the bloodstream and the bloodstream is the super highway of the body. We have to get those nutrients to every living cell on the body, from the hair on your head to your you know, pinky toenail, things are moving through the gut into the bloodstream and getting out all over the place so they’re intimately connected.

Dr. Wong:

So, would you say that when you see a dermatologic condition as a naturopathic dermatologist, is that where you would start, with the gut? You know, if someone’s coming to you with a huge rash or something and they say, “Hey. Can you help me with the rash?”, you know. Where do you kind of start with them?

Dr. Greenberg:

Right. So, I have a two-pronged approach. I am going to prescribe botanical topicals and those are gonna you know, I want to alleviate some of the issues that are happening on the skin, right? And we can address even some root causes on the skin and we can get into that like with eczema and psoriasis but again, the root causes, I’ve got to go to the gut so on pretty much every patient, I do gut microbiome testing and I’ll just take a minute to explain to your listener base if they’ve never heard that term gut microbiome. What I’m talking about is that the average adult human has between three to five pounds of microbes living in their gut and it’s everything from bacteria to fungal organisms, that can be yeast and molds, even critters like protozoa or worms you know, we don’t want those guys but sometimes they get in there so it’s a whole host of microorganisms and it’s

three to five pounds. That’s a lot and who’s in there really really matters so when I say you got microbiome testing, I want to see who’s in there. Specifically, which organisms. Who is there too much of it that doesn’t belong there or it’s overgrowing and where is it deficient. Where are there too little or there’s missing good ones that we actually need and in order to do that, I run two functional medicine tests on virtually every patient. One is a stool test. I warn my patients, you will be pooping into a tray, you will be collecting your own stool, it’s going to be gross for a few minutes and it will be over. The second is a urine test, that’s a lot easier for most people, just pee in a cup. And the reason I’m asking them to do this is because I get a picture. I get reports on the actual microbes in the gut and I’ve done hundreds and hundreds of these gut microbiome tests on patients and I started seeing patterns and I started when I was looking at the labs. I would forget oh you know, I forgot what that patient had but I would look at the labs and I would say, “Oh. Somehow, I know this is an acne gut. I think this is an acne patient”, or I would say, “You know, this is an eczema gut”, and last year, I actually published the research on the gut microbiome of my acne patients and the specific set of problems I see pretty much unique to acne. It’s very different than the other conditions. This year, I hope to publish a similar paper and medical research poster on the gut microbiome of my eczema patients because it really varies by disease what’s happening in the gut. It’s truly fascinating.

Dr. Wong:

Great. We’ll take a deep dive into those and we’d like to definitely post your researc, too. That would be great. Thank you. And then, how does nutrition impact our skin and then a follow-up to that I think would be do you recommend certain diets or I guess dietary patterns to improve skin health?

Dr. Greenberg:

Yeah. I mean I think when we talk about nutrition, there’s kind of a micronutrient discussion and a macronutrient discussion and again, for your listeners, maybe they’ve heard those terms, they don’t know exactly what’s the difference. Macronutrients are things like proteins, carbohydrates, and fats. The body breaks down foods into those various component parts and we utilize that for energy and building and then, there’s micronutrients which encapsulate things like vitamins and minerals that are also essential for our health and they they come a long package with the food so we get micro and macro nutrients from the food. I think there’s a huge industry for micronutrients and supplementing hair skin and nail stuff for example, biotin. In the dermatology world, I think we’re a little perplexed like who does the PR for biotin because it’s some amazing PR that gets done but really if you look at the research, most of the studies show that you can supplement all the biotin you want but unless someone’s really deficient, it’s really not going to start sprouting hair on their head or you know, doing magical things but still, every hair, skin and nail supplement has a huge load of biotin in it and patients will actually ask for biotin so again, a great PR rep for biotin, whoever’s doing that. I don’t know how that got started.

Dr. Wong:

It might mess up the TSH level though, that’s the only thing.

Dr. Greenberg:

Not just TSH, there’s a whole host of labs. A troponin which is super serious because we use that to determine heart attacks, testosterone. Yeah, there’s a whole slew of labs, you’re right, that if a patient is supplementing with biotin, they should absolutely go off for many days before doing the test because it can completely come back with false levels. So, yeah. So, for micronutrients, I don’t have like, oh here’s the hair, skin, and nail supplement. For some of the tests, the organic acid urine test that I do, it does test for metabolites of B vitamins and there are certainly times when I’ll see some B vitamins that are deficient. For example, riboflavin or vitamin b2 is often deficient with candida and or other fungal overgrowth so I may like supplement that while I’m treating the fungal overgrowth but in general, I’m not going at it with like hair, skin, and nail formulas by any stretch of the imagination. For macronutrients, every patient has homework after our first visit and the homework is that they have to track the food that they’re eating for about three or four days but all I care about is their fiber totals so I focus a lot on getting fiber up to 35 grams a day and 30 different vegetables a week for patients. There are times where there’s a gluten sensitivity marker on the stool test, there’s indications that they really shouldn’t be eating gluten. I’m also not a big fan of dairy especially for my acne patients, there is no friend to you if you have acne. But in general, I’m focused less on what they can’t do and more on what they can do which is we gotta work on 35 grams of fiber and 30 different vegetables a week. The reason for that we need that level of fiber intake to maintain a healthy gut microbiome so I’m going to see a lot of gut dysfunction, I’m going to have them on a lot of herbal protocols and supplements to fix that what we call ‘dysbiosis’ and correct it but I always say to my patients, my goal for you is for you not to have this derm problem, for you not to have to see me, and for you not to have to be on a ton of supplements. That’s not the way the body has evolved to work and though I’m going to get you there you know, working you through all these protocols but I want to send you on your way and the way to say smooth sailing is to eat that much fiber because that is going to keep the good guys in your gut happy and that really just keeps your balance in your gut so that’s mostly what we work on.

Dr. Wong:

Got it. I love the idea of the 30 different vegetables per week. I think the last time I thought about that was doing a CSA and then finding vegetables that I never saw before, you know?

Dr. Greenberg:

Yeah. I have patients to do something called a ‘rainbow check’ which is when they go to the market they do a first pass around the produce aisle and then they look in their basket and they go through the colors of the rainbow, red, orange, yellow, green, blue violet, what color is missing from my basket and they do a second pass and get those in and it’s actually not hard to get 30 different plants a week. I mean things like you know nuts and you know, all plants count but we wanted to really focus on fiber but once you focus on different colors and you know you’re shopping with seasonal changes, you’re going to work diversity into your diet which is the key because a diverse diet crafts a diverse microbiome and that instills resiliency and health into someone.

Dr. Wong:

This is something I wasn’t thinking we would talk about today but I think we really should because it’s like a chicken or the egg thing with people that have had damaged guts and maybe they even have SIBO like small intestine bacterial overgrowth. The question is, can they tolerate that much fiber, this many vegetables? How do you how do you deal with that with your patients?

Dr. Greenberg:

Yeah so I have a lot of SIBO patients who come to me and when it’s with them, what bothers me is when I get SIBO patients who have been on a low FODMAP diet for like six months or more, they’ve starved the good bacteria and I already know what I’m going to see on the stool test which is something known as insufficiency dysbiosis. It means that all of the good guys are just at so such low levels and every single time, anyone on a ketogenic or a low FODMAP diet for long periods of time, they all come back with insufficiency dysbiosis so I don’t do a low FODMAP diet but what I do do is say, “Okay, where are you at with your fiber now?”, and for most patients, I’m trying to ramp them up to 35 grams of fiber a day adding a vegetable a week. For my SIBO patients, we don’t do that at first. We say, “Okay. You’re averaging 12 grams of fiber a day. Okay, we know that. We’re gonna put a pin in it for now”, and I try to use my herbs and supplements to decrease the gas and bloating you know, and it depends. If it’s more constipation, I want to move the stool. If it’s more diarrhea SIBO, I want to slow the stool down so I want to make life comfortable for them first and then once their digestive tract has calmed down and they’re not suffering in the same way that most SIBO patients are suffering, then we can slowly start to work in foods and you know, I’m not going to start with like large amounts of garlic and onion or high FODMAP foods but I don’t even really worry about that. I just I just have them very slowly you know, add in, try different vegetables, see what’s working but I can usually get the gut calmed down enough in a protocol like in a two-month cycle that the next time we can start working on adding in some vegetables and they tend to do pretty well with it.

Dr. Wong:

That seems to be a very sensible approach. Another question about the skin. I know this is something a lot of listeners would be interested in. What can we do to improve collagen in our skin? You know, we know that their collagen is really helpful for skin health overall.

Dr. Greenberg:

Yeah. So, I think there’s a couple things that we can do. I mean there’s collagen supplements and you know, I’ve heard vegans and vegetarians ask like, “Oh,is there something I can take?”. Their collagen is from animal sources so it can be marine based so if you’re a pescetarian, you can have fish or you know chicken or beef or whatever but it’s going to come from an animal and there are actually studies there was a meta-analysis and systematic review that was done at the end of last year that actually shows that supplementing with at least five grams of collagen, which normally it’s eight or eleven if you do a scoop, actually did decrease wrinkles and improve skin texture after three months so I don’t mind if patients want to supplement with a high quality collagen supplement. It can drive histamine though so if you’ve got a patient with mast cell or eczema or an underlying histamine issue, it might not be a great time to supplement with collagen but in general, you know, of course I’m gonna like natural food sources so a bone broth soup, that kind of thing. You know, people eat chicken feet and things with collagen like if you can stomach it, eat the actual animal. We used to eat the entire animal, we throw away most of the animal but a lot of people can’t stomach that. But, there’s also things that we can do to support the existing collagen so when people eat sugar, it creates something called an advanced glycation end product or an AGE and basically, you can think of it like it’s the same thing that happens if you caramelize sugar in a pan, what happens? It turns crispy crunchy and brown, right? And I talked to patients that when you eat sugar, it’s doing that to your collagen. It actually connects up to your collagen and creates like crunchy crispy collagen and nothing will age someone faster than sugar so one thing is like let’s preserve the good collagen that we’re making and not add in ages and you know, mess up the collagen. So again, we’re going to go back to the fiber and the plants, the phytonutrients you know, those are going to all create healthy good collagen but then there’s also topicals. Things like aloe vera gel will enhance collagen production and there’s an enzyme we have in our skin called collagenase so there’s collagen and elastin and there’s also elastase. Those two enzymes break down the collagen and elastin in skin and as we age, we start, unfortunately, increasing the production of those enzymes which is why we start to wrinkle and get laugh lines as we age. There are botanicals again like aloe but there’s essential oils that I use in serum base oil serum blends like frankincense and lavender that have been shown to suppress the production of those enzymes in the skin. Now, I don’t want your listeners to go out now and buy essential oils and start putting them on. First of all, never use essential oils neat which means never put the essential oil directly on your skin. That’s a very good way to create a contact allergy and possibly burn your skin. I always work with you know a licensed health care provider who’s knowledgeable in essential oils and products but I do

love essential oils when they are being prescribed by someone who is knowledgeable about them.

Dr. Wong:

Nice. So many things, so many pearls of wisdom just dropped there. Definitely one of my favorites is on the ages because it’s such an appropriately named mnemonic, advanced glycation end products. Sugar will age our skin it sounds like by creating ages with the collagen. Yeah, great. Let’s get into another vitamin or I should say vitamins/hormone, vitamin D and we know that there’s probably two camps and everywhere in between in terms of some people are like you know, and I’m curious your thoughts on this as well . Some people you know, wearing sunscreen. When you wear sunscreen, when do you not to get the vitamin D and so, how do you manage getting vitamin D which we know is a hormone right as well through sunlight but also wearing sunscreen to take care of your skin?

Dr. Greenberg:

Yeah. It’s an excellent question and one that I’ve been moving much more in the direction of what you just said, getting it through sunlight versus supplementation. So, if you do a conventional blood test and get back your labs, the threshold for like a low vitamin D is like around 30 or 32 depending on the lab so it has to be quite low for you to come back as truly frank low. For most naturopathic or more kind of functional medicine doctors, I mean it varies like for me, I’d like to see it much more up around 50. I used to do vitamin D supplementation to try to get it up there but the more research I did and the more I heard about it and thought about it you know, all the studies show yes, absolutely, vitamin D levels correlate to a whole variety of diseases you know, everything from multiple sclerosis to even you know eczema and psoriasis, people tend to have low levels of D but the problem is when they do studies and they supplement them with artificial D to get their levels up, the levels go up in the blood but the conditions, there’s just a lot of like very conflicting evidence about whether it makes it better and if you look at you know, more like a meta-analysis or systematic review and for your listeners, that’s where instead of just looking at one study, we’re looking at a lot of different studies and seeing like across all the studies that were done you know, did we actually see that this thing is helping? The answer kind of seems to be no, that artificial supplementation of vitamin D doesn’t really seem to do much to help these types of dermatological conditions so I moved away from vitamin D supplements and moved towards in my treatment plan, there’s a line that says lifestyle and underneath it it says aim to get between 5 to 20 minutes of sun a da. Now, the caveats on that, I don’t actually want them to expose their face. UV radiation and sunlight for sure is one of the greatest agers of skin that we are exposed to so there’s no doubt about it that you know, the the sun and UV radiation will age your skin and we don’t actually make a lot of vitamin D from our facial skin anyways so I feel like this is not the area where we need to get the exposure so you know, we talk about trying to expose you know arms legs and torso for those five to twenty minutes if they have a balcony or a backyard you know, walking out. I live in LA so shorts and a tank top, pretty easy year round. It was just 74 here over the weekend and it’s winter. I know that’s not always feasible in other places but I really am moving towards sun exposure and we never want to burn, right? So, we’re never going to stay out long enough. If they get a little bit pink so I say if you take your finger and you push it on your skin and you get a little pink blanching, that’s okay but it should disappear within 30 minutes of going inside. If you still got pink after that time then you’ve stayed out too long and you’ve burned yourself and it is going to change in terms of the time of year and what latitude a patient is at and their skin tone so they need to figure that out but all of my patients, I recommend that they get some daily sun exposure because I think the answer that you know, what we’re seeing in that, people are low in vitamin D but supplementing doesn’t help. There’s probably a lot more benefits that we get from sunlight and we are discovering some of those benefits and that vitamin D may be more a marker of appropriate levels of sun exposure. I mean we know that there’s things that D can do for us but either the form that we get it in supplement is not equivalent to you know, what we get from nature which I think that’s true of most things and/or that it is also just a marker of sun exposure but we’re missing out on the other benefits of the sun by supplementing artificial D and and I think there’s so much left to discover about the sun. I mean we know there’s seasonal affective disorders, SAD. People literally get depressed when they don’t get exposed to the sun in some places. That’s not just vitamin D, that’s the sun. We are not vampires, you know? We are meant to be in the sun and participate with sunlight and I think that it’s really a problem when patients aren’t in the sun and there there are studies, big long-term large studies that show that a lack of sunlight is actually a huge morbidity and mortality factor and that we do need sunlight.

Dr. Wong:

So, one of the big take homes I’m getting so far is we have to move to LA or at least take a vacation there. Beautiful area.

Dr. Greenberg:

Yes. I mean, right, prescribing a patient a vacation in a sunny tropical place for winter, I think most patients are gonna be pretty okay with that.

Dr. Wong:

Yes, exactly. That’s great. We’re just interviewing a PhD who did her dissertation and vitamin D research and she was saying and I don’t understand the details fully but she was saying that when you take a supplement orally, it’s almost like mimicking your gut microbiome instead of where the skin is kind of stimulating your skin microbiome so there could be something with that too.

Dr. Greenberg:

Yeah, yeah. It’s true because you know, I mean we make sunlight through the skin and that is a different way. I mean there’s certain plants like mushrooms that have been exposed to the sun where we can get small amounts of vitamin D from food but you know really, the majority of the the sun, the vitamin D that we make comes from sun so that’s fascinating.

Dr. Wong:

Yeah, so kind of balancing getting the vitamin D through sunlight when appropriate in the right season, the right latitude, etc., but also wearing some sunscreen to take care of

the skin when needed. Speaking of sunscreen, do you recommend you know, to prevent burning and things like that once people have gotten that 15-20 minutes depending on their melanin content and stuff? What kind of sunscreen would you recommend at that point?

Dr. Greenberg:

So, across the board, I recommend physical sunscreen. Only a physical sunscreen is going to use an active ingredient, most often zinc oxide, it could be titanium dioxide as well. They’re a chemical sunscreen, for your listeners, are other things like octanoxide able benzone, they are chemicals and the sunscreen will say put this on at least 30 minutes before you go in the sun. The reason is for chemical sunscreen it has to absorb into the skin and have a chemical reaction and then be ready for you to go in the sun. A physical sunscreen like a zinc oxide, you put it on, you can go immediately into the sun. It is called a physical sunscreen because it is a physical blocker it sits on top of the sun and reflects back the rays of the sun so it’s not seeping in, you don’t need to put it on 30 minutes before going out so I only recommend physical sunscreens. There was a study in Jama, it was maybe 2020, that showed that we do absorb even with one application significant amounts of chemicals from chemical sunscreens and I just don’t think we need that in our system especially when the physical sunscreens are good options and I actually also like a tinted sunscreen especially for the face. The tint in the physical sunscreen is something called iron oxide so it’s another natural mineral but what’s great about it is it blocks blue light from the sun and blue light from the sun is not stopped by the UV blockers so none of the zinc oxide or chemicals will stop blue light but blue light can cause hyperpigmentation so either if someone has melasma or even if they have inflammatory problems like acne, there’s something called post-inflammatory hyperpigmentation where basically the skin darkens but the tinted sunscreen with iron oxide will block the blue light and prevent that from happening.

Dr. Wong:

Got it, specifically for the face.

Dr. Greenberg:

I do, yeah. There are body tinted ones but that can get a little bit messy.

Dr. Wong:

Yeah, got it. And then, for the zinc oxide and the physical sunscreens, is there a difference between the ones with and without nanoparticles? Don’t some have or is it all?

Dr. Greenberg:

Yeah. If there’s different sized particles and there’s debate like do the nanoparticles actually get through into the bloodstream and what’s happening. I think that a lot kind of remains to be seen in this area. Exactly, what’s happening. I don’t tend to concentrate on it too much. The reason they created the nanoparticles was because you know, when they first made the physical sunscreens with zinc oxide, if you put it on everyone would look like Casper the friendly ghost and it just was this white crazy you know, mess on them. Now, most companies have done a good job of creating physical sunscreen so that you don’t look like you’re wearing a white paste but yeah, I’m kind of like waiting to see where the research goes on, the nano versus non-nano. I’m not sure how I feel about it yet.

Dr. Wong:

Yeah. Maybe more research needs to be done. Thank you. Well, let’s let’s get into some of the root causes, some of the common skin conditions that you see. First of all, what are the top three, four skin conditions that you see in your clinic typically?

Dr. Greenberg:

Yeah. So, I think it mimics the population. My top two for sure are eczema and acne then after that, probably like psoriasis or maybe even alopecia areata. I treat a lot of alopecia areata but I see rosacea and seborrheic dermatitis usually kind of overlaps with other stuff as well but there’s definitely a lot of subderm as well.

Dr. Wong:

Let’s just start with something basic before we get into eczema, acne, and everything, we’re really excited to look into all that. What if someone just has dry skin you know, and what’s kind of going on with that and this is a really general question that I think would be you know, helpful for listeners. What do you think about showering and like how often do you shower in relation to healthy skin?

Dr. Greenberg:

Yeah. So all of my patients for the first visit, there’s an education portion that usually lasts about 30 minutes so I’m a naturopathic doctor, we have very long visits. My first visit is either 90 minutes or two hours and 30 minutes of it is educating. That’s a tenant of naturopathic doctors is doceri or doctors teacher and part of the thing that we go through is skin health and it’s pH so pH is really important and just to remind your listeners, you probably studied pH back in junior high. You had the little litmus strips of paper and you were testing them on different liquids to see if they were acids or bases and they’d change color and you’d line them up on the color strip and they run from 0 to 14. so 0, 1, 2, low pH are acids. High pH up at like 12, 13, those are basic or alkaline substances and things at the middle like at 7 are neutral and that’s things like water and the body has evolved to operate at an optimal pH depending on where you’re at so the blood is neutral and it has to be very tightly regulated. The skin is surprisingly acidic and most people when I have them guess, “Where do you think the pH of skin is?”, most people will go for seven which is neutral because it’s like blood, water that feels safe that should be skin but we have something on the skin called a fatty acid mantle and we just heard the word acid so we actually know automatically that skin is meant to be acidic and for me, healthy skin starts with acidic skin we cannot have healthy skin without the correct pH. There’s a couple of reasons for that. One is that we have things called antimicrobial peptides on the skin like dermcidin and defensin and their job is to just be there and if some bad guy gets on the skin, it’s their job to kill it and beat it up and make sure that that doesn’t happen but the second thing that most of my patients don’t know and like hearing is that when we have acidic skin, it actually ages slower so acidic skin will naturally have fewer wrinkles and dark spots than a more neutral or alkaline skin so we always start with how are we going to find topicals and how are we going to keep the skin in its happy acidic state because our general protocol for skin, what do we like to do in America? We use soap and hot water. Well, soap is always going to be alkaline because it is a chemical reaction between lye and fats so that’s just by nature, soap is alkaline so whenever you wash your body especially with hot water, you’re stripping off the fatty acid mantle that protects your skin, you’re raising the pH of your skin and then you kind of wish it good luck. That is going to dry out your skin, that is going to raise the ph of your skin and I have never treated more hand eczema and hand dermatitis since COVID started because people are like compulsively washing their hands with soap and hot water, they’re stripping off the fatty acid mantle, they are raising the pH of their skin and they’re setting themselves up for hand eczema so the first thing is we always work on these natural products that are going to support the skin. Of course, soap is good. We love soap, right? We don’t want to stink, there’s COVID afoot, we can handle raw chicken, we use the toilet, lots of excellent reasons to use soap but we want to use natural soaps. We don’t need to over scrub and then we want to re-acidify the skin, pull that ph back down. That is going to make the skin more moisturized and healthier so those are some basic things that I talk about with every patient and then for me, I don’t like lotions. I separate my topicals with oil-based and water-based products and so we go through all the different things to use to keep skin healthy basically.

Dr. Wong:

Great. I have some follow-up to that but let’s go into some of the conditions. So, you said one of the top conditions that you see is eczema, what are the root causes of eczema and then what kind of general kind of treatment do you recommend just as a general kind of category?

Dr. Greenberg:

Yeah. So fundamentally, eczema is a problem with skin barrier dysfunction, we can see that, an inflammation and it’s not just inflammation on the skin, it’s inflammation in the gut. I definitely have a two-pronged approach to eczema. I guess we can start with the skin stuff so one you know, we talked about pH and that the skin is acidic. Well, how does the skin get acidic? Why is the skin acidic? We have to go to a protein in the skin called filaggrin and it’s what we call the master regulator of the skin barrier and out of filaggrin, we make something called natural moisturizing factor, NMF. What a great name substance, right? I don’t even need to explain to patients what natural moisturizing factor is. It’s like quite obvious so it’s one of the main things in keeping your skin moisturized but natural moisturizing factor is made up of acids so of course, it’s acidic. It’s what sets the acidic tone for your skin. Well, in eczema, especially my patients who have had eczema since they were infants or small children, you can have something called a filaggrin gene mutation, FLG, or in African-Americans, FLG2, and what that means is that those patients, they just naturally don’t produce as much filaggrin and natural moisturizing factor on a daily basis as other people might. That doesn’t mean that they are doomed to a life of eczema, it just means that they’re predisposed to getting it and so a filaggrin gene mutation and a lack of filaggrin and natural moisturizing factor is one of the problems with eczema but the other problem is Staph aureus on the skin so staph aureus is an organism, a bacteria, that we think about as like infections like if you’ve heard of impetigo ,that’s a full-blown staph or strep infection but staph can cause problems even when it’s at lower levels than infections but it’s over colonizing the skin so staph is intimately tied with eczema and anyone who’s having an eczema flare is basically having an overgrowth of staph aureus on the skin and it absolutely needs to be addressed. Now, you don’t need

to have like a prescription, topical antibiotic like mupirocin. I treat it every day with antimicrobial topicals and one of the best ways to beat staph is to again pull that skin down to a healthy pH because staff likes the skin at about 7.5 and if we get it down to a five, staph has a real miserable time and it’s gonna go find another home but the other problem with staph is it colonizes the nose so I also treat all of my eczema patients with a nasal spray to get the staph where it’s colonized, it’s on the skin, it’s in the nose and we’ll get to it, it’s in the gut so staph is a huge topical problem in eczema. A malassezia yeast can be another problem, it’s why a lot of eczema patients, infants, will have cradle cap but a lot of the adult patients will also have either dandruff or kind of a secondary subderm on top of the eczema so there’s the skin problems that I need to take care of but as far as the gut goes, based on the labs that I see and run, I would say there’s two main problems. There’s overgrowth of three specific organisms and there’s a leaky gut and the leaky gut is there because two of the very good species what we call keystone species that help maintain a healthy gut are gone or they’re at very low levels and these are long names but it’s Faecalibacterium prausnitzii and Akkermansia muciniphila but it’s a whole leaky gut picture and the organisms that are overgrown in the vast majority of my eczema patients are staph aureus in the gut so now we’ve seen it three places on the skin, in the nose and in the gut. Again, that crosstalk that we talked about. Candida yeast and strep, those are the three organisms that are overgrown. Now, everyone’s an individual so there’s usually more going on but that’s the eczema gut, is those markers, and when I’m looking at the labs that’s pretty much I know my eczema patients.

Dr. Wong:

I love treating the root cause and how you beautifully explain the the bifurcated you know, skin and gut treatment. It just makes it so clear so thank you so much for that. Let’s kind of go to acne you know, acne does really torture or bother a lot of people out there I’m sure, not only starting with teenage years but even afterwards, right? I mean is there an age limit to acne or is it kind of a?

Dr. Greenberg:

Yeah, it’s amazing. So, you know, when I was growing up but my generation, it was really much more of a teenage problem and those numbers have shifted. Adult acne is hugely prevalent. Men and women in their 20s, 30s, and 40s, up to 50 percent report ongoing issues with acne and even up to 25% of women in their 40s are still dealing with acne. You know, at some point, it will burn out. I don’t think I have any 60 or 70 year old patients with acne but I’ve got 40s and 50s who still have acne so it’s ongoing. For me, acne is also very much a gut problem. I mean we know that there’s stuff happening on the skin and in the hair follicle, we can get into that but yeah, it’s hugely an adult problem now in a western society and I probably treat more adults than teens even.

Dr. Wong:

What do you think that’s from? That shift in the the age you know, demographics of acne patients?

Dr. Greenberg:

So, I think puberty is a kind of a setup to again, like in the same way that a filaggrin gene mutation will kind of predispose you to have eczema but it doesn’t mean you need to. Puberty is a kind of setup for acne, right? Because this is a time of high growth and high hormone production and when we look at what’s actually happening that is causing a pimple, there’s kind of four steps in what we call the pathophysiology of acne or what’s actually happening. The first step is overproduction of sebum and sebum is oil in a hair follicle and most people don’t realize that acne only occurs in a hair follicle and your listeners might think well I’m a woman, I don’t have hair on my face but you do you have tiny little vellus hairs, the little blonde guys, and even those little vellus hairs have a sebaceous gland whose job it is to produce sebum so the first step in acne is too much sebum production then we can get too much skin cell production. That hair follicle becomes clogged and we can either have bacterial acne. It’s often due to an organism called cutibacterium acnes or fungal acne due to malassezia, which I mentioned with eczema. And so, when we look at being a teen you know, we think of acne associating with being a teen because that is a period of high growth and high hormones like testosterone and even insulin and those drive sebum production so it’s not that every teen has to have acne but it’s certainly a setup and within a cell, there’s a growth process called mTOR, mammalian target of rapamycin, and we know that mTOR is going a little bit out of control in acne and mTOR is already fired up in puberty because it’s meant to be growing things so I think that’s why we certainly see it in up to 90 percent of American teens are going to get acne because their mTOR is already cranking and on fire and. If it just gets a little bit too much of a push then it’s like well, we’re building all these things. I guess let’s start pumping out some sebum too. But in adults, you know we’ve seen this switch now which is why are we getting all this adult acne and for that you know, it’s not mTOR on fire because of puberty. We have to figure out why is mTOR activated and there’s a whole other host of reasons that I go through with my presentation with patients, they all know these terms. mTOR is being activated in adults for a variety of other things but our western diet, meat, wheat, dairy and sugar, they all drive mTOR but some of the organisms in our gut seem to impact the process as well and it’s completely in line with what I see on the gut microbiome of my acne patients so.

Dr. Wong:

Yeah. I just love how you keep on drilling down on how the gut is so important in the microbiome whether it’s insufficiency dysbiosis or an overgrowth. And it’s so interesting, I’m really excited to read the research you’ve been doing on you know, different I guess microbial signatures and we might be talking about the same stool test. I imagine we are but you know, different stool tests that are very specific towards you know, different organisms and yeah. Let’s let’s kind of get into treatments for acne. I mean there’s obviously the conventional type of treatments and we all know that they can be you know, helpful at time but then there’s a lot of side effects potentially too so what are your thoughts on treatments there?

Dr. Greenberg:

Yeah. So, I’m going to go at it, I guess kind of there’s like a three-pronged approach for acne so a topical is one. I want to use things that are going to naturally try to calm down inflammation and reduce sebum production. I don’t generally use pharmaceuticals so I’m not going to be using like retinols or topical antibiotics or anything like that. I use natural botanical topicals and things like you know, aloe and hydrosols which are water-based plant extractions are gonna get that skin down to an acidic pH so that the either the malassezia or the bacteria on the skin is not able to dive into that follicle as much and get trapped and there’s actually oils that are very good for acne. We think of, “Oh no. If you have acne, don’t put an oil on it because that’s going to make it worse”. It’s not true. There are comedogenic oils or clogging oils like I would never put coconut oil on the face but there’s other very good oils for the skin that are light and can actually calm acne down like a grapeseed oil or pumpkin seed oil can be beneficial and a blend of essential oils to reduce that sebum production then internally, I want to reduce the sebum production but I need to address the gut and the issues that I see most commonly in the acne gut are candida overgrowth, H. pylori overgrowth and protozoa overgrowth and for your listeners, protozoa means first animal so it’s a little single celled, we group it as an animal organism and there’s lots of different types of protozoa, everything from a more pathogenic like giardia to a Blastocystis hominis or an Endolimax nana. All of them for me I treat, all H. pylori I treat and so I’m going to use specific herbs and supplements to treat whatever I see on the labs but then, I can also use some supplements to try to reduce sebum production and calm things down and slow down that mTOR process and of course we’re always working on fiber and plants which naturally calm mTOR and sebum production as well.

Dr. Wong:

Yeah. Fiber’s the base, get the short chain fatty acids and got it.

Dr. Greenberg:

Yeah, yeah. And speaking of short chain fatty acids so in my eczema patients, the ones that are lacking the Faecalibacterium prausnitzii, that’s a main butyrate producer. Butyrate is a short chain fatty acid. I will often supplement with butyrate while I’m trying to restore the gut because those short chain fatty acids and butyrate are so important to colonic health, to lowering inflammation, to enhancing tight junctions of the cells in our gut. You know, I always tell my patients, it’s kind of weird to think about like why are we housing three to five pounds of microbes in our gut like that’s weird, right? It’s a freeloader. We’re carrying them around everywhere you go. You’re carrying an extra five pounds and you’re feeding them, why in the world have we evolved like this? And the answer is of course, they do things for us that we need, we cannot live without them, we can’t be healthy without them. And so, we really need to craft to think of them as you know, your pets that are doing good things for you. Without them, everything goes wrong and it’s so much easier just to build a healthy gut microbiome and let them do what they’re supposed to do rather than trying to supplement 50, 000 things and fix it on the back end.

Dr. Wong:

Yeah. I was just laughing because you know, a lot of the microbiome scientists say that we’re freeloading on them, right?

Dr. Greenberg:

But I like to think we’re kind of like a B&B, right? We’re a bed and breakfast.

Dr. Wong:

Yeah.

Dr. Greenberg:

It’s like we give you a home and we’re going to feed you three meals day.

Dr. Wong:

That’s right, that’s right. It’s it’s a pretty good B& for.

Dr. Greenberg:

Yeah.

Dr. Wong:

That’s great. Let’s talk about psoriasis, you know. Psoriasis is another condition that isn’t quite as common as eczema and acne but it is. There’s some genetics there, there’s some certainly nutritional factors, things like that. What are some root causes you found for psoriasis and what are some of the natural treatments that you recommend?

Dr. Greenberg:

Yeah. So, psoriasis is an interesting disease, you know? We obviously see it happening. I mean there’s different types of psoriasis but plaque psoriasis is the most common one. There’s mutate and inverse and all sorts of stuff. It got put in the dermatology bucket like back in before the 80s because it was like oh, we’re seeing these plaques so it’s a derm problem and then over the years, we’ve really realized that it’s much more of an actual immune problem and it’s a systemic inflammatory immune disease with many more repercussions than just plaques on the skin. Honestly, pick an organ system and people are to increase risk for problems with just about any system. And so, we think about that inflammation and there’s a lot of conventional drugs now that are offered for treatment of psoriasis that are effective. They are effective in suppressing inflammation and getting rid of the plaques but they are not effective in terms of getting to the root cause so as a naturopathic doctor, we’re always asking but why, why? We’re like two-year-olds. We don’t stop asking why and you know, the real question is why is the body creating all this inflammation? Instead of just trying to push the inflammation down, let’s figure out why the body is creating the inflammation and catch it and stop it here so when it comes to psoriasis, not surprisingly, I do the stool test, I do the urine test and I do usually see a large amount of overgrowth in the gut, leaky gut and there’s often this kind of third component of a toxic element whether it’s mycotoxins or heavy metals or environmental toxins but one thing I talk through with all my patients is the immune system so in psoriasis, there’s something called Th17 cells and so T cells are a type of immune cell we have in our body and Th17 cells are a specific type of immune cell and anyone who has psoriasis has a huge army that they’re building of these Th17 cells and there’s other cells Th1 and some other ones but we’ll just make it simple and talk about th17 cells so all the inflammation is coming from this army of Th17 cells. When we just look at immunology, why does a body create an army of Th17 cells? Well, it’s bacterial and fungal invaders at mucocutaneous sites. Okay, let’s break that work down. What’s mucocutaneous? Well, muco is mucus, cutaneous is skin and a lot of people don’t realize that one of the largest mucocutaneous sites in the body is the gut. We have to create a thick layer of mucus along the whole gut and that is the barrier so if we don’t have that thick layer of mucus, we have a leaky gut. That’s fundamentally what leaky gut is. And with psoriasis, if you have a leaky gut and there’s bacteria and fungal elements like candida yeast for example that are getting in through your gut into the bloodstream, that is a very good reason for your body to start building an army of Th17 cells. Now, Th17 cells are kind of pathognomonic for all autoimmune disease so this is true for my vitiligo patients my alopecia, areata patients. I love treating alopecia areata so much because you just work the gut and the hair grows back, it’s just beautiful. So really, I think with psoriasis, it really is again being driven through the gut and we know there’s lots of studies that show that there are in the psoriatic plaques, there are contents from the gut microbiome, there are things like polyamines so things are absolutely escaping from the gut and getting through into the bloodstream and then into the skin. Now, why does somebody have psoriasis versus alopecia areata or a different autoimmune disease? There’s a genetic component to it, right? Someone is predisposed to getting certain diseases because of their genetics. Again, it doesn’t mean that you’re going to necessarily get psoriasis even if it runs in your family. It’s in in functional and naturopathic medicine, we like to say that genes load the gun but environment pulls the trigger so unless you pull the trigger, you’re not going to get the disease but for me psoriasis, it is this Th17 cell army being driven by fungal and bacterial problems at mucocutaneous sites. I think immunology explains it beautifully. I do do things topically to kind of slow down the production of skin cells and calm the plaques down. There’s a beautiful herb called indigo naturalis which as the name might give you a hint, it’s blue so you got to be a little bit careful with where patients are putting

the indigo bomb because it will rub off onto sheets and clothes and stuff but it’s very good at decreasing those Th17 cells and increasing T regulatory cells which are another

type of immune cell that kind of came for tolerance and a calming force on the immune system.

Dr. Wong:

So, decreasing those Th17s and increasing the T-regs it sounds like is what we want to do with most autoimmune conditions.

Dr. Greenberg:

Yes.

Dr. Wong:

You know, you’re such a wealth of information here, Dr. Greenberg. Love to have you on for another session if you can. I think I just wanted to conclude with first of all, thanking you for being on this episode. I know a lot of listeners are going to find value in all this and you know, skin health, everyone knows it’s important but it’s not just important for cosmetic reasons. We all want shiny, vibrant skin but it really is obviously the large organ our bodies and communicating with the gut microbiome and really affecting a whole system so thank you for all that . I just have one question. Are there any resources you recommend for finding reputable products for skin care? You know, we all go to you know, giant or whole foods or whatever and it’s like what do you get from there?

Dr. Greenberg:

Yeah and it’s tough because we don’t have a lot of regulation in this country when it comes to our skin care products. In Europe, it’s much better and more tightly regulated so the quality of skin care products that you would get there are going to be much cleaner naturally than here because companies can get away with using cheaper chemicals that are not so great for us so there’s a couple of tips I can give to your listeners. One is there’s the EWG, environmental working group’s skin deep or something database. If I’m saying that wrong, you can.

Dr. Wong:

Yeah, yeah. That’s right, yeah. Everybody that’s ewg.org skin deep or something.

Dr. Greenberg:

Yeah and they’ve got just a whole really easy to use website where you can key in the name of like products and it will tell you kind of the safety rating. Now, I don’t agree with like all of their ratings but by and large, it kind of gives you this green, yellow, red picture that’s pretty easy to understand so that’s one thing, check your products there. On another level, I think just very basic, treat it like your food. So, most of my patients, if they’re picking up a packaged food, they’re gonna turn over the label and read the ingredients and I think with ingredients you know, we’re going for ingredients that we understand. Once you get to a long label with a lot of multi-syllabic chemical sounding names, it’s probably not a food item you want to put in your basket and bring home for you and your family. It’s not going to be healthy. The fewer ingredients, the more you understand what it is, the better it is. Your skincare is that way, too. The tip I can give listeners is what I said before, you separate your water and your oil based products. I don’t like lotions. I’ll get on my little lotion soap box here for two minutes. The reason is, lotion is a combination of oil and water. Well, what happens when we put oil and water together? I think we all did this science experiment in fifth grade and we see that they don’t mix, they float and they are completely separate so how do companies get a lotion? Well, they have to use a chemical called an emulsifier to smash together the water and oil at the molecular level and keep them there so now we’ve got a ton of emulsifier. And now that we have water in the product, you have to have preservatives. There’s no option. So, when you use a lotion as a moisturizer, you’ve got oil, water emulsifier, preservative. Emulsifier and preservative, that whole class of chemicals are going to be the ones that tend to fire up red on that type of EWG working database. They are not natural, they are not good for your skin, they are not good for you. And the oil that is used in a lot of cosmetic problems are petroleum or mineral oil which are byproducts of the gas and you know, oil industry. These are not good oils. So, by taking away lotions, we have solved the problem. We don’t need emulsifiers, we don’t need preservatives and we don’t need to use petrolatum or petroleum or mineral oil. So, what do you want to look for? A natural base soap, something like a hydrosol is a great toner. It’s a water-based plant extract almost like a tea and then for the quote-unquote moisturizer, I just use a serum which is a blend of oils and essential oils. They’re going to be plant oils and you know, essential oils and again you want somebody who knows what they’re doing to have formulated it but it is great for your skin. These are acidic, you’re going to age slower, your skin is going to be healthier, it’s just all good.

Dr. Wong:

Thank you, Dr. Greenberg. Love to have you back for round two of this because I think we have a few other things to talk about but thank you so much and thank you for all of you listening out there. We know that this episode is going to be really well received. This is a really important thing to talk about, skin. A lot of things you know, maybe we need to buy more European. I know there’s a lot of European products on the market as well, they are more regulated there. Yes, I agree with that just from other things knowing about supplements but I didn’t realize that about the skin products so yeah. Thank you so much, Dr. Greenberg again and looking forward to having you back sometime.

Dr. Greenberg:

Thank you so much. I’d love to come back.

Dr. Wong:

Thank you for taking the time to listen to us today. If you enjoyed this conversation, please take a moment to leave us a review. It helps our podcast to reach more listeners. Don’t forget to subscribe so you don’t miss our next episodes and conversations and thank you so much again for being with us.