This Is Why 99% of Skin Conditions Don't Heal — And What Dermatologists Won't Tell You

You said that muscle building is one of the best ways. It's a non-skin care intervention for healthier skin in midlife. Can you kind of unpack that?

There is a study that was really interesting about women in their kind of midlife age range. They compared them doing aerobic exercise to strength training. The participants who were strength training actually had a thicker dermis, you know, so dermis is where our collagen sits. When you're strength training, you're increasing insulin sensitivity, and then that kind of takes a load off of your cells. You're decreasing inflammation as well. Your mitochondria are optimally functioning. When your cells in the dermis are affected by that, they're gonna work better. They're gonna build more collagen.

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Thank you so much for having me.

You know, I've never had a dermatologist on. I'm very excited about this because when I started practicing functional medicine 30 years ago and treating people's health issues, I would notice that their skin would get better by improving their nutrition, by optimizing their gut flora, by helping them get rid of toxins, by dealing with, you know, food sensitivities. And it was quite, it was quite amazing to me how things that were really chronic persistent conditions like dermatitis issues, like eczema, psoriasis, acne, rosacea, like a lot of the bread and butter stuff. Just people have, it doesn't go away and it has to be managed. It has to be managed. It has to be treated with medication. It's, and you know, traditional dermatology is at least the way I learned it. 'Cause I'm a family doctor. I learned dermatology, you know, basic dermatology, basic stuff was to put lotions, potions, gels, salves, creams, whatever you could put on the top to actually fix the problem, whether it was steroids or antibiotics or antifungals or whatever the thing was. If it's wet, dry, if it's dry, wetted, whatever, like the—

Right, right. Yeah. That's how they would teach that.

And I came to quickly understand when I started practicing functional medicine was that the skin health is really coming from the inside out. Yes. If you have sun damage, yes. If you, you know, do things that harm your skin from the outside, it can be an issue. But a lot of skin health and the treatment of chronic skin conditions, which a lot of people suffer from, is from the inside out. And it's dealing with the foundational things of nutrition, of gut health, of optimizing nutrient status. And so I think that I kind of want to get into, you know, how you came into this field from a traditional dermatologist and sort of had this awakening that— and I know you kind of were sort of a little bit open to this because your mother's Japanese and you learned about Eastern medicine and how you really kind of flipped the switch and said, oh, maybe there's a different way to approach these chronic dermatological conditions that cause so much suffering. So tell us how you kind of started to kind of understand that there was a different way of thinking about it. And let's sort of unpack some of the basic foundations of integrative functional dermatology.

So like you mentioned, my mother's Japanese. So just from a young age, I've been exposed to alternative approaches to healing instead of just, you know, suppressing symptoms with, you know, an over-the-counter medicine or prescription medicine. My mom would incorporate modalities to to really get to the root cause or what I would think. And so it just kept me, you know, you know, gave me an open mind. And when it came to applying to medical school, I was like, do I wanna go to a naturopathic medical school versus like an allopathic conventional medical school? And I was so torn.

Hmm.

And I decided, you know, if I went the conventional route and got my MD, I could always practice, you know, holistic forms of medicine, functional medicine. Uh, with that background.

Interesting.

And, uh—

It's kind of the same thing happened to me. I was gonna study Chinese medicine. I'm like, yeah, you know, like, I think if I have an MD behind my name, I can do more stuff and people won't think, think you're a problem. Yes. Yeah.

And oh my gosh. And as you know, like when you're in med school and residency, I just feel like I just got sucked into this vacuum. I was basically just trying to survive, like just studying all the time, not sleeping.

The hazing is brainwashing.

It really is. It's like, it's so ironic, like just the health, like stress that we put our bodies through with medical Residency and medical school. And so, I definitely experienced a lot of health issues just going through all that. And, and really there's derm residency, even though derm is kind of a fun, more, you know, people think it's like a, a fun field. It's not as, some people don't take it as seriously as like, you know, thoracic surgery, but, but it's such a hard residency. There's such a learning curve because there's so much to learn in derm residency that you don't learn in medical school. And so, I just kind of got sucked into that and went into conventional private practice. But I was always interested in taking a holistic approach. Like I was president of an integrative medicine interest group during med school. And as I was practicing, you know, as you mentioned, we put a lot of, we focus a lot on skin, like topical treatments. We do a lot of systemic treatments as well, but so much of it revolves around suppressing inflammation.

Oh, steroids. You can use oral steroids, but that's another, it's a pretty serious—

Yeah, oral steroids. It's, it's—

It's like using a nuclear bomb for a local—

Yeah, it's like using a nuclear bomb. And long-term use, there's so many issues that come with that. But also even like biologics too, which are— they're safer than steroids, but there are also a lot of ramifications with biologic use.

And biologics, just to interrupt you for a second, is basically this class of drugs that suppresses your immune system.

Yes.

And, you know, generally works well and doesn't have as much side effects, but does increase the risk of cancer and also lowers your immune system function. So you're more likely to get serious infections.

Yeah. More so with the anti-TNF class, the newer classes, They're becoming more specific, so they are more safe. But still, yeah, it's the premise of they're all suppressing your immune system. And it's just like, let's just shut up the immune system so that you can live in peace. But what I've noticed just practicing more and more is that it's not really getting to the root cause. Like, I'm so grateful for these treatments because it makes people more comfortable. It makes them survive their day-to-day, but it's not really getting to the root cause.

So how do you then think about approaching dermatology now from this new set of lenses and perspectives that you have about how skin health is really from the inside out, and it's a systemic problem, not just a skin problem. Your skin is a reflection of what's happening in the rest of your body. So how do you think about that? How do you approach these patients who come in with these really intractable conditions that require basically a sledgehammer? We use sledgehammers in medicine.

I know we do.

And it's just, you know, there's a different approach.

So when somebody comes in, obviously take a thorough medical history, Look at their background. But I also go beyond that and look at what they're eating, how they're sleeping, what the stress is like in their life, what hormonal changes they could be going through. Are they going through menopause? What are their environmental exposures? Are they traveling a lot? What kind of environment are they living in? And, you know, what are their— what's their exercise habit like? So really taking all of that into consideration and— taking that into account before I come up with a treatment plan for them.

So what tend to be the root causes that you're seeing, like clinically in practice? Like what are the things that are coming up over and over again that you're like, oh, I didn't learn this in residency or medical school, but this is actually something that is real, that when I change this thing, it works.

I would say gut and hormones are like the 2 biggest things that we see when it comes to a lot of the major skin issues, whether it's acne, eczema, psoriasis, rosacea, hair loss even too. You know, we're not really addressing those in conventional dermatology. We have a lot of wonderful treatments, like I said, to suppress the symptoms. We have a lot of things that can help acne, whether it's spironolactone or isotretinoin, but, you know, it's not really healing the underlying triggers.

Yeah, that's true. Like, I find that, you know, you start with nutrition and the gut, and then you kind of work on optimizing that, and then you kind of see what's left over. And then, you know, there are other things that might be playing a role, like You said hormones, we'll get into that. Mitochondria, we'll get into that. Exercise, we'll get into that.

Yeah. Insulin sensitivity.

Insulin resistance, which is a big thing for skin health, which people don't realize, which is affecting to some degree 90-plus percent of Americans. At Function Health, with our diagnostics, we measure insulin on everybody, which is not something most doctors check. And we're looking at the reference range from Quest, which is 18 or above is abnormal. I mean, really optimal is probably less than 5. I mean, I'm 3, 2 to 3, you know, as someone who's 66, who's healthy, who's fit, is like metabolically okay. 'Cause I know what to do. That's kind of optimal. But we're seeing even at the reference range of Quest, 65% of members of our over half a million members have high insulin levels and have inflammation.

Oh God.

You know, you're probably familiar with Nicholas Perricone, and he wrote The Wrinkle Cure way back when.

Oh, correct.

And it was all about like inflammation and oxidative stress. And so the question is like, what is causing this inflammation? What is causing all this damage? And it's things that we can actually identify. So diagnostically, how do you think about approaching these patients with these chronic illnesses? What are you testing? What are you looking for? How do you sort of do an essential differential diagnosis, but based on a new set of lenses that you're looking through?

There's people who come in wanting to, you know, help their skin with wrinkles and like kind of coming in for anti-aging treatments. So that's a separate kind of diagnostic approach. But for people coming in with chronic inflammatory issues, whether it's acne, psoriasis, eczema, I do think that it's really important to look at their gut health. And I will often collaborate with other functional medicine docs or naturopathic doctors to do gut testing and really do a thorough examination. Is there yeast overgrowth? Is there an imbalance somewhere there? We do know that there are higher rates of SIBO in rosacea, like that's been established, higher rates of Helicobacter pylori. And, you know, we see that in acne as well, really looking at that and targeting those things if they show signs.

Even fungal overgrowth for rosacea.

Oh, fungal overgrowth, definitely. When people come in with acne, another thing I really like to look at is their insulin sensitivity or their resistance, testing their insulin level, and even looking at the ratio of insulin to their fasting glucose, I think gives even a more accurate picture of what's going on with their insulin sensitivity. And yeah, in terms of testing, those are the main things. And like I said, if we need to do more extensive testing, like Dutch test to look at their hormones more closely, I will include, you know, another, you know, collaborative physician who has more experience in that.

Yeah.

But I do think that patients get frustrated and they're like, I just want to know why I have this. They're grateful for medications, but they're like, if I stop it, then it comes right back.

So, it's not really solving, you know, I also find that checking gluten sensitivity and antibodies to gluten is a big one, especially for certain conditions, whether it's psoriasis or— there's a lot of data that gluten can be a player.

Yes. Yes. There, yeah. Even like in non-celiac patients, gluten can be a player in certain forms of psoriasis because some people with psoriasis can test positive for those antibodies. And for those patients, I do tell them to stay away from gluten. And then like some random other like dermatitis flares, we can see gluten sensitivity.

And acne is another one. Acne is a big one. You mentioned insulin resistance, but again, when you have high insulin in women particularly, it can cause high testosterone. And then sugar. So sugar is a big factor in causing acne. People don't realize that.

Oh, huge. Yeah. Sugar and dairy.

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Yeah, well, it's huge. And like, if you talk to, you know, like my partner who'd been practicing for 40 years, she said, we did not see this much adult acne that, I mean, teenage acne has been around for a while, but adult acne has been rising in the last few decades. And it's like, it just makes you wonder what else is going on in our environment. Yes, I think that agricultural practices have changed, like what we're feeding cows, and like that could be affecting milk, the meat, all like the other endocrine disrupting chemicals that could be out there.

And glyphosate destroys microbiomes.

Glyphosate, yeah. I mean, we're seeing more acne alongside like more rates of hypothyroidism, more hair loss, more infertility. Like there's something going on in our environment that's affecting our whole endocrine system, I think, 'cause these are all hormone-based, a lot of it. And like I also have my other theories. Like I do think that we live in a more stressed environment too. Stress is so huge when it comes to acne. As well as, you know, all these other inflammatory skin issues that we see. Stress can, you know, increase cortisol. So cortisol just sends a whole cascade of signals, including just like increased inflammation in our skin, increased— it makes our sebum more sticky. So like we get more acne from that too. And yeah, so, so we see that. And, and I'm not telling people to stop drinking coffee, but sometimes I do think that it can— if people drink too much caffeine or consume too much, that can artificially increase like their stress response in their bodies too. So that's something I also talk about with patients. I'm like, what's your sleep like? How much caffeine are you consuming? I sort of go in there as well.

Yeah. I don't know if you kind of adhere to this theory, but a lot of these skin conditions are inflammatory.

Oh yeah. Yeah. Inflammation, I would say, is the base for everything.

Yeah. And so typically in medicine, we use anti-inflammatories or immune suppressants or steroids basically to calm the inflammation down, but rather than going to the root of like, why is there inflammation? So could you, could you share a little bit about like your experience with some of these things and, and what you've seen?

When it comes to You know, I'm just trying to think of like patient examples. I had a patient with terrible acne, and she had all these side effects to the conventional treatments, spironolactone and isotretinoin, and she would respond to them, but she kept on getting— like, so spironolactone can affect your periods, and she was not having her periods, which wasn't the problem, but she was also just getting a little bit too dehydrated from it.

It's kind of a diuretic that also blocks testosterone, so it can help with acne.

Yeah. And then with isotretinoin, she was getting joint pain. So we were working with a functional medicine doctor, and she did some gut microbiome testing on her and saw that she did have yeast overgrowth and fixed her yeast. But she also did some hormonal testing as well and gave her certain supplements to just help kind of with the hormone balancing. And her skin cleared. She didn't need any conventional treatments, which I was thrilled about. Thrilled about, honestly. And yeah, and then, you know, when I talk about when patients come in, like psoriasis too. So with psoriasis, I find that these patients have so many other issues going on. They have cardiovascular issues like metabolic syndrome. So, and then pre-diabetic, they have hypothyroidism, they have low vitamin D. It's like a full picture with psoriasis. So I try to also do other work I, I do look at their thyroid. I do look at their lipids and their vitamin D and, and make sure that we're addressing all of those things. They're usually sleep deprived. I find that a lot of people who do like night shifts where their circadian rhythm is completely flipped upside down, that really sets off psoriasis. It sets off a lot of inflammatory skin issues, but we do see circadian rhythm disruption being a huge one with psoriasis. Yeah.

I've seen a lot of psoriasis patients and I find it's one of those slam dunks of functional medicine. And even though it's such a, they call it the heartbreak of psoriasis, it's like, you know, and the things that I found were Gluten are really top of the list. So anybody who's got that, I get checked for sure. Gut issues and leaky gut and food sensitivities on top of that. And also overgrowth of yeast, which is a common one. And then heavy metals, which are kind of often overlooked. And so if you kind of dig around on those, usually you can find a way through. You need to find a good practitioner like you or a functional medicine doctor to do, because it's not something that traditional doctors even think about.

They don't. I know. And I wish there's a lot of like, People, I don't know, I feel like a lot of controversy out there on like doing some of these forms of testing, but, but to me, we can't, we don't have all the answers with the conventional testing. And so, yeah, I know, I really appreciate like your mission to, to really bring about these other forms of how do we find out the root cause of these patients, whether it is with heavy metals or gut microbiome testing.

And the truth is there's not a lot of research money going towards these modalities of nutrition, of gut health, of things that are really kind of not long-term long-term treatments. Because think about it, if you get someone on a drug for acne, like a retinoid, I mean, they're kind of on it. So it's great for the drug company. But if you treat someone and they get better and they're off everything, not so good. So there's not a lot of incentives for doing the foundational things. It doesn't mean that because there's a lack of large double-blind randomized controlled trials that it doesn't work. I always say the absence of evidence is not the evidence of absence. And I think as a clinician, I'm observing things over and over like you are. And I'm seeing that, you know, there's a there there. And yes, we need more research. And thank God that the Medicare, the Center for Medicare and Medicaid Innovation put up $100 million to study chronic diseases using functional medicine and lifestyle medicine, which is amazing. There's, there is some things happening, but that doesn't mean we can't already just take advantage of these things because they're generally low cost, they're low risk, and they're very safe to do. Changing your diet, changing your lifestyle, exercising, taking a few supplements. Let's talk about nutrition. Yeah. What, tell me your philosophy around what should be like a healthy skin diet and also like what do you use when you start to treat these chronic issues like psoriasis or eczema or acne or so forth?

Yeah. When it comes to a healthy skin diet, most of the evidence comes back to a Mediterranean-based diet. Basically, I would just call it like a well-balanced diet. So adequate protein, adequate healthy fats, low sugar, adequate fiber. I think fiber is also an underrated thing. We're seeing definitely low fiber correlate with a lot of issues, a lot with acne. But anyway, so, so that's the basic premise. But we also want to make sure that we're adding like adequate nutrients, vitamin C, polyphenol-rich foods or supplements. But, but I would say foods would be the best route if you can do it. And other flavonoids as well as like carotenoids are huge as well, whether it's like beta-carotene or astaxanthin. So foods rich in those ingredients. I— it's tough because I try not to be overly restrictive with patients. I feel like it ends up backfiring. But I'm like, if we can at least make the goal of making it more balanced, you know, making sure you're having your fruits and vegetables. I know that sounds so cliché, but doing that and making sure you're having adequate fiber, healthy fats, minimizing the processed foods, minimizing the sugar, that's where we have the most evidence.

Those are foundational principles for general skin health. But then when it comes to people with chronic conditions, like I find that elimination diets can be a great place to start.

Yes.

Basically gluten, dairy, sugar.

Yes.

It's like, it just makes such a big difference.

It makes sense. So, where we have the most evidence for acne, it's dairy and with sugar. When it comes to dairy, it's more so skim milk than it is whole milk, but the evidence is pretty compelling for really all forms of dairy. And then when it comes to— and then increasing fiber too. We're seeing that lack of fiber is also contributing to acne.

Because it affects the microbiome.

Yep, exactly. Yep. And then there's also this idea where if you're not, you know, regular with your bowel movements, it can cause a buildup of like certain hormone metabolites as well that could potentially contribute to acne. So something to think about when it comes to psoriasis. Most of the evidence, like I mentioned, is Mediterranean diet, healthy fats. I try to supplement with omega-3s and vitamin D and then gluten.

It's interesting.

From what I learned is that if they do have a sensitivity to gluten with like certain antibody testing, then I would definitely have them go gluten-free. I'm not as adamant about it if they're negative with those tests.

I find it's worth trying because there's 2 parts of your immune system, as obviously you know, but for people listening, there's the one that's forming antibodies, which we can test for, and there's the one that doesn't form antibodies, which is the ancient immune system or the innate immune system. That doesn't form antibodies. And there's a, there's a good body of literature that a lot of people react to gluten from the innate immune system, which is not measurable. So I, I find it often like a good, you know, it, you know, just is a good kind of test for like 2 or 3 weeks and not forever. And then, and then you see what, like, are there foundational nutrients you recommend for the skin? You mentioned omega-3s, vitamin D.

I keep it pretty basic. Omega-3s, healthy fats in general, whether it's, you know, avocado, nuts, Fish. I mean, not all the time, but kind of incorporating the ones that are smaller. Like, I like sardines. I mean, if you get wild-caught salmon, great. And then when it comes to other things to incorporate more fiber, so that's just vegetables in general, fruits in general, but there's really not like one specific thing. Like I mentioned, carotenoids. I tell people really try to eat the rainbow. And I know you've— like mentioned this too, for, for in general, for like for skin issues. But, um, there's not like, oh, if you eat more of this specific food, you're going to, you're going to get all better.

Yeah. Well, Nicole's parent was talking about like wild salmon. I think the omega-3s are so big. I find that if I would say like, what is the one clearly like clinically effective skin nutrient that I've used over and over again for skin, hair, and nails, it's omega-3s. If someone's low in omega-3s and at Function Health, we test everybody for the omega index and, you know, you want to be over 8%. Most people are not. Most people are quite low. And so, you know, we don't get a lot of wild animals or wild plants or wild food, which is where typically these omega-3s are. So I think it's important to supplement. Talk about how hormones play a role in skin and how— I know you've talked a lot about sort of female health and reproductive health and some of the things that happen around menopause. Like, tell us about how you help women think about their skin health. And then we will get into the aging and that, like, how, because I think we've been talking clinically about what are the health pathologies, let's say, which are diseases of the skin. But then we're going to get into like, just how do you make sure your skin ages well? And that's sort of topic 2 we'll get to. But I want to sort of just talk about sort of hormonal dysregulation because you did mention gut and hormones as key drivers of skin dysfunction.

Huge. Yeah. There's different types of hormones. There's estrogen, progesterone, testosterone, the sex hormones. And then there's also thyroid hormone, which plays a big role with a lot of skin issues. And then insulin being another hormone. So I, I see all of those playing a role with how we age and how that can contribute to inflammation in our skin. So, I mean, just to kind of touch on each of them, when we see thyroid issues, we see more dry skin, we see brittle nails, we see more hair loss.

Mm-hmm.

We see, yeah, just like like decreased wound healing time, just like the circulation's not as robust. So, so, you know, when I see those issues, anytime somebody comes in with hair loss, I always check thyroid. When it comes to insulin, we talked about acne. So insulin resistance, we see more so in acne. We can also see it in psoriasis. It can also contribute to accelerated aging. So that's something we'd like to look into. And then when it comes to the sex hormones, and you mentioned menopause.

Mm-hmm.

So, you know, we have a drastic drop in estrogen, when in like within the first 5 years of menopause. And estrogen is huge when it comes to just overall skin health. It plays a role. And testosterone as well. Testosterone goes down too. And I'll talk about what the benefits are. But, but with estrogen, it activates fibroblast activity. These are the cells that help build collagen. So that's, that's how, you know, collagen production goes down. It also contributes to increased like hydration in the skin, whether it's increased hyaluronic acid or just increased increased lipid production in our cells. So, so our skin barrier becomes altered, our skin becomes more dry when we have less estrogen. And it also plays a role in like the thickness of our skin. So we have what's called epidermal atrophy, and that's where you get like that kind of that crepey skin, um, kind of in that postmenopausal period.

Mm-hmm.

So estrogen plays a really big role with that. It works alongside progesterone. And then like testosterone, testosterone's really huge when it comes— and the androgens in general when it comes to like oil production. And so that plays a role with skin barrier dysfunction. That's why we always see dry, itchy, people as they get older. Everyone just gets more dry.

So are you a fan of hormone replacement therapy for women?

I am a big fan. I think it does wonders for your skin. Yeah.

And how good is the, how good is the data on that?

Uh, we haven't really, there, I don't think there's been like, been a lot of amazing studies that are dedicated to looking at skin health. And I would love for there to be more. It's more just, it's kind of a side effect that we've been seeing.

So you basically clinically observe this and, and, and I think it's true. I think women do notice that. And I think, you know, like you say that these hormones are really playing a role. So You talk about insulin resistance, you talk about thyroid dysfunction, then you talk about, you know, sex hormones all playing a role. So I think, I think, you know, getting your hormones tuned up is super important. And as particularly women, as they go through perimenopause and menopause, there's so many things that start to happen. They get more insulin resistant, their thyroids often go wacky, their sex hormones are going wacky and everything's kind of flying outta— and then they're, of course, their stress hormones are going wacky 'cause they're in the middle of this sandwich generation with older parents and younger teenage kids and, you know, careers.

Yeah.

And it's like, it's kind of a soup of, of dysfunctional hormones of insulin, thyroid, sex hormones, and cortisol and stress hormones. So I think that's often not really well addressed with traditional medicine, but there's ways to look at these things. There's ways to understand where you are. There's ways to work to optimize your health with these, both with hormone replacement therapy, but also lifestyle, diet, and so forth. Let's sort of get into skin aging because I think it's a sort of a separate topic that I want to dive into. But I just, before we do that, I just want to close on this first bit by saying that if you have a skin issue, if you have psoriasis or eczema or rosacea or acne, which are the most common ones, did I forget any? Did I forget any?

Yeah.

Yeah. These are the bread and butter, right?

The bread and butter of flammatory.

These are things that have solutions that you're not necessarily hearing from your regular dermatologist, that a functional medicine approach, integrated medicine approach can really help solve. And sometimes it takes a minute to figure it out, to unpack it, to be a detective, but It's, it's worth going into that route. And sometimes it does mean modifying your life a little bit. Like sometimes you can't eat gluten. Sometimes you can't eat dairy. Sometimes you have to fix your gut. Sometimes, like there's things you have to do.

It takes work, which is why I think so many people don't do it too.

Yeah. But the other alternative is just to be miserable.

Exactly. No, no, no, for sure. For sure.

Yeah. Sometimes when you're craving something sweet, the answer isn't necessarily to have more willpower. It's worth asking what your body might actually be asking for. And one thing I pay attention to is whether I'm getting enough protein throughout the day. Protein is important for satiety, for muscle, for providing the essential amino acids our bodies need. And that's one reason Perfect Aminos has become part of my daily routine. I take it every day because it's a simple way to supplement my protein intake with all 9 essential amino acids without adding a lot of calories. I especially like having it on days when I'm traveling and working long hours, or just know that I haven't gotten enough protein from food. It's a small thing, but for me, For me, it's become an easy part of my everyday routine. If you're looking for help to fill protein gaps, go to bodyhealth.com and use the code HYMAN20 for 20% off. If you've been listening to this podcast for a while, you probably heard me talk about Seed. The probiotic category is full of big promises and not always a lot of proof to back them up, but DS-01 is different. It's the number one digestive health probiotic. And when you look at the science behind it, it's easy to understand why. There are 3 things that set it apart. First, it contains 24 unique probiotic strains to support the diversity of your gut microbiome. Second, its capsule-in-capsule technology helps protect those strains through digestion to reach the colon, where most other probiotics just die in your stomach acid. And third, DS-01 has been clinically studied and has shown to reduce bloating, alleviate gas, and improve regularity. That's not just marketing, that's real clinical evidence. And that level of scientific rigor is exactly what led me to join Seed's clinical board and why I continue to recommend DS-01 and take it myself, even after all these years. Go to seed.com/hyman and use the code 25HYMAN to get 25% off your first month. That's seed.com/hyman and use the code 25HYMAN. I had quite an amazing patient. I'll just tell you quickly, who has psoriatic arthritis, which is like an advanced form of psoriasis that affects the joints.

So hard.

And it's a tough condition. And at Cleveland Clinic, we did a study where we took our patients in our Center for Functional Medicine, were treated by the functional medicine doctors who had psoriasis or rheumatoid arthritis, comparing it to the rheumatology patients in the rheumatology department, which is rated number 1 in the world for rheumatology at Cleveland Clinic. So these people know what they're doing. They're really good. And they're trained in the— and the fellow looked at our data. We didn't analyze the data. They looked at our data. They used all their traditional rating scales that they have in medicine for rheumatology.

Uh-huh.

And we did better across the board. in outcomes using functional medicine, not using drugs compared to them using all the drugs.

Doing the usual things like looking at their gut.

The gut health, nutrition. Yeah, everything. Elimination diet, the usual stuff. And it was like, I think it was shocking to them, but it was like obvious to me. I had a patient who was a psoriatic arthritis patient who had multiple other issues. She had prediabetes, she had migraines, she had depression, she had irritable bowel, she had reflux, and obviously psoriasis. And arthritis. And she was taking Stelara, which is a very expensive immune suppressing drug. And she was taking a bunch of other drugs from all, like her neurologist and her psychiatrist and her gastroenterologist and her endocrinologist for her diabetes and her prediabetes and her migraines and her, you know, it's like, and they're all like, these are the best doctors in the world and they're giving them the best treatments for their, but they're all treating like a blind man and the elephant. And I'm like, what is the common denominator in this patient? It's inflammation.

Mm-hmm.

All these migraines are inflammation, prediabetes inflammation, irritable bowel is inflammation, reflux inflammation, joint pains inflammation, actually psoriasis and skin inflammation. And I said, look, I don't— she has severe bloating and severe reflux and all these symptoms. I think you have SIBO, which is bacterial overgrowth in the gut. I think you probably also have fungal overgrowth given how many antibiotics and steroids you've been on. And so I basically gave her an non-absorbed antibiotic, Rifaximin, and I gave her an antifungal. Not typical treatments for psoriasis.

No.

And I gave her some probiotics and vitamin D and fish oil, I think probably a little zinc or something, and not a lot. And then I put her off gluten, dairy, sugar, processed food. I basically put her on my 10-day detox diet, which essentially is an elimination diet that gets rid of all the potential triggers for short-term. She came back 6 weeks later and she said, I'm better. Like, I have no psoriasis, no arthritis. I stopped all my meds. I said, I didn't tell you to stop your meds. She said, well, I know, but I felt better. No migraines, no prediabetes. She lost 20 pounds, no more reflux, no more irritable bowel, and no more depression. And depression is also inflammation, right, in the brain. And so I was like, this is an example of a way that traditional medicine misses the boat.

Mm-hmm.

They just kind of don't understand how to think about the problem. And that by using these other sort of filters to see the same symptoms and the same diseases, we see a different set of issues that are going on. And it's almost like we put on special glasses, like you put on infrared or night vision glasses and you was like, oh, I see what's going on. And then she, you know, she, but, but this is not, people say, oh, it's an anecdote or whatever. And I'm like, yeah, I, I've done this for 30 years and I can tell you there's hundreds and hundreds, if not thousands of patients across the spectrum of different diseases that have responded this way. And not everybody responds to everything. And sometimes it's a puzzle. And like I had a patient with eczema, I couldn't get better. And I, then I figured out it was mercury, but it's just, it's really about being persistent. So if you're listening out there and you have these issues, don't give up. There's a way forward. You might have to change your lifestyle, but it works. Let's get into aging. What's happening in terms of like skin as we age? Like what goes wrong and how do we improve? Because you see some people like who look like 100 when they're 45 and people who are like 90 who look amazing.

Oh yeah, there's different things happening at the different layers of our skin and I'll just like briefly touch on it. So, you know, the top layer of the epidermis, as we get our cellular turnover gets more sluggish. It slows down. So that contributes to just kind of more dull, uneven skin. And I think of that phrase, like, smooth as a baby's butt, because literally, like, babies, their skin cell turnover is every 2 weeks. As adults, it's every 4 weeks. But then, like I said, as we get older, it just becomes more sluggish. So, so that's what creates, like, the buildup of dry skin and, like, uneven skin tone. So there's that. And then, you know, we have our melanocytes, which sit at the base of our epidermis, and these are the cells that produce pigment. And their activity just becomes more sluggish. Like unpredictable, like some just poop out. They're like, I'm just going to like release all this pigment. And we get like more sunspots and like uneven pigmentation as we get older as well. And then we're also, you know, producing lipids and we have sebaceous glands that are living in the dermis, but then they get released into the epidermis. And lipids are also responsible, like I mentioned earlier, for keeping our skin hydrated, keeping our skin barrier intact. So as we get older, we get more dry skin. And then below the epidermis, we have the dermis. And the probably the biggest component is collagen, which sits in the dermis. And I mean, there's other components— elastin, hyaluronic acid, or what we call glycosaminoglycans, which are these sugar molecules like hyaluronic acid that sort of like live between the collagen fibers and support the collagen and elastin. And as we get older, we get breakdown of collagen, we get more disorganized collagen and elastin, and that contributes to wrinkles that we see. And that's a natural part of aging. But there are certainly things that accelerate that, which we can talk about. Below the dermis is the subdermis or the subcutaneous fat, which, you know, as we get older, fat decreases as well. And then below that is bone. As we get older, like our bone, our bone starts resorbing and like, yeah, yeah, we have decreased bone structure. So like, I think of it like a mattress, you know, like the mattress cover is like our epidermis and then the springs are like your dermis and then the actual bed frame is your, you know, your bone structure that's supporting everything. And so, so we need all of that to look like a very appealing bed.

From your perspective, Given what you know with functional integrative dermatology, how do you think about skin differently with aging? How do you, how do you help people take care of their skin differently with nutrition, lifestyle, hormones, gut, supplements, and skincare? Because topical stuff does matter.

It does matter. And yeah, if you were to ask a conventional dermatologist, there, you know, there are a lot of things that we have so much evidence for, decades of evidence topically that can help your skin, whether it's retinoids, sun protection. Uh, there's other things like vitamin C, like topical antioxidants. Yeah. But there are also things that we can do internally that really help our cellular activity repair the cells. And like you mentioned, nutrition, stress, sleep, other like environmental like stressors. I mean, we know that UV is huge, but whether it's pollution or like other like endocrine disrupting, you know, chemicals, these all come together. And then also just being sedentary too. These all just come together and accelerate aging. Oh, sorry, I forgot to mention cigarette smoke. I mean, a lot of people, I feel feel like are not smoking cigarettes as much these days. People still do, but cigarette smokers do this. Yeah, very common there. But yeah, cigarettes and alcohol definitely just create more inflammation.

Okay. Cigarettes, I think people understand if you smoke, you look kind of haggard and you get wrinkles fast. And if you want to wrinkle and age quickly, definitely smoke. But alcohol, I don't think people know. Can you talk about alcohol and skin?

Yeah. Alcohol can accelerate skin aging. So our bodies are exposed to a variety of different toxins, but our liver thankfully is there to help stop or to help just kind of decrease that toxic burden. But when that burden accumulates, if our liver is stressed or distracted by things like alcohol or potentially other medications, then that toxic burden can increase and increase stress on our cells, what we call like oxidative stress. And that causes cells to not function as well. So when it comes to collagen, we're not building collagen. Inflammation from oxidative stress can also break down collagen more quickly without—

So Nicholas Perricone was right. Oxidative stress and inflammation are key So, so you mentioned collagen a few times. People hear about collagen, um, and they take collagen supplements. Is that a thing? Like, is there data on it? Is it just, is it just window dressing? Like, what is actually going on with the whole industry? Because, you know, people think, oh, I'm taking collagen, I'm getting collagen. Is that actually happening?

I know it's, it's not a straightforward answer. I would say overall, yes. I think that there's enough data to support collagen consumption, But, you know, a lot of the data that is pretty compelling is industry-backed. So you kind of have to take that with a grain of salt. Anecdotally, I do see— I do see a lot of improvement in patients who do take collagen peptides. And yeah, just because you take collagen peptides doesn't mean that that collagen goes to your skin. It's more so that the collagen peptides can send signals to help your body build better collagen. But I also advise patients You, I'd rather you also get better sleep, get sun protection, decrease the stress in your life, strength train. I would rather like have that all dialed in before you're incorporating collagen peptides. I don't think it's like the easy switch to just add collagen peptides.

You can't eat crap and be stressed and not sleep and just take a bunch of collagen supplements and think you're fine.

Yeah, exactly. But the short answer is yes, I do think that. I'm on team collagen.

Okay, great. Amazing. I think that's helpful. I think I've always wondered, 'cause I, you know, I think they're, they're good and they Gut.

Gut.

But I always wonder, do they get really absorbed and used properly? But the other thing you sort of, we didn't really get into yet was sort of the sun.

Yes.

And, you know, I think UV radiation. And then, you know, when you get a sunburn, that's because the sun's creating oxidative stress and inflammation and damaging the skin. And that's why you get sunburned. And that creates lasting damage. How does that work? And what happens in the mitochondria in the skin? Because we didn't really talk about mitochondria, which are basically little energy powerhouses in the cells, but they are also key to skin health. And can you kind of tie that together, how all that connects?

UV radiation is probably the number one extrinsic factor that contributes to skin aging.

So beauty from the outside in, but also sun from the outside in. Sun from the outside in. Inside out and outside in.

Yeah. I mean, yeah, we know genetics plays a role and all these other things, sleep, stress, nutrition, exercise, these all play a role. But, but we, but by far it's, and smoking too, but by far it's, it's UV radiation. And yes, as you mentioned, it increases oxidative stress in our cells. Basically, it's, it's causing like a localized stress response within our cells and it's causing DNA damage. And, you know, it's all fine because if you're healthy, we have the DNA repair mechanisms in place that go in and like repair that DNA. We have like the antioxidants that can fight those free free radicals, those unstable molecules from oxidative stress. And, you know, we can repair and heal from that, but with enough hits, your body's like, okay, like, we've done enough. And that's why you see those con— the consequences of just prolonged and like just chronic sun exposure come out later in life, because it's like your body has already done so much to try to combat that, that it just comes out later in life. And so when you have this oxidative stress within your cells from UV radiation, it affects the function of the organelles, and namely mitochondria.

Mm-hmm.

The mitochondria, I mean, as we age, As you age, mitochondrial function does decline, but stressors like UV radiation definitely accelerates the mitochondrial dysfunction within the cell. So, when your powerhouse of the cell, the mitochondria, aren't working as well, then that cell itself will create more oxidative stress to your body. And like, your body just has a harder time like fighting it. Like, it's almost winning. And then, so when your cells aren't working well in the skin, you get more collagen breakdown. Like, those are like the fibroblasts, which are the cells that make your collagen. Yeah, don't work well. And then, yeah, it just continues. And then like your epidermis, the keratinocytes, the top layer of your scalp there. I mean, our skin's a dynamic, living, breathing organ. You know, we think the skin's just there to like make you look good, but no, it's doing so much. It's— our cells are constantly regenerating. We're building things. So when you have that mitochondrial dysfunction, which like in addition to UV radiation could be from a bunch of other things, but when you have that, then yeah, that's where you can see a lot of cellular aging and then skin aging from that.

Something people don't really talk about is like, you know, skin health related to mitochondria.

Mm-hmm.

And how much energy it takes to have healthy skin. As we age, you said the mitochondria become more injured and damaged just because of aging itself, because of insulin resistance, because of generalized inflammation in the body, because of sun damage, because of poor diets, because of all these reasons that we accelerate mitochondrial injury. And it doesn't just affect the energy in the cells, in our tissues and organs, but in our brain, but also our skin. And I think some people don't really realize. And then I would love you to talk about this process of sort of how do we take care of our mitochondria? And how do we think about like the repair and regeneration renewal of mitochondria? There's a concept in medicine called autophagy, which means cellular cleanup, essentially means self-eating. Like at night when we sleep, our bodies will gobble up with lysosomes all these old parts and recycle them. But also the mitochondria have a process like that too called mitophagy. So can you talk about mitophagy and skin and how that all connects and how accumulating damaged mitochondria leads to more skin aging and how to use mitophagy to help clear and fix that for healthy skin aging?

Yeah. And there's multiple ways to address mitophagy. So, yes, mitophagy is what you said. It helps clear out that kind of the damaged mitochondria, the mitochondria that aren't functioning because they're really just like taking up space and then the cells aren't working as well. So, to optimize mitophagy, we want to decrease the stress in the cell, the oxidative stress in the cell. So, doing things like decreasing processed foods, Those can, you know, add to the stress in the cell, decrease UV radiation. And that's a whole nother topic because I know the sun is important too.

Vitamin D.

Circadian rhythm, vitamin D, all of that. But there's a way to do it responsibly. But yes, but minimizing the chronic UV exposure. So there's that, there's nutrition, actually, you know, sleeping adequately. Sleep is when we're doing so much repair, not only, you know, with within our skin cells, but like our whole body. So, so important. And then stress, minimizing stress. Stress contributes to more oxidative stress literally within our cells. So minimizing that. I know we've talked about strength training. When it comes to exercising, we know it's nourishing our cells like with the circulation, but it's also improving things like insulin sensitivity. And when you have just all these other markers functioning better, then unless— and you have less inflammation, your mitochondria are going to work better. So by By minimizing all these things, you can help.

And it also increases the number and the—

Yeah, the number of mitochondria.

The function of mitochondria with exercise.

Oh yeah, definitely. Yeah, yeah, I know exercise, I think, is like so amazing for mitochondria. And there's also supplements that you can take too. Like, we live in a toxic world, so it's hard to really combat all of these stressors with our bodies. I mean, yes, we do have—

You need the foundations, but supplements help.

You need the foundation, but supplements do help. And things that are anti-inflammatory are helpful. I mentioned, you know, we talked about omega-3s for a while. And then, you know, vitamin D supplementation can also help with that oxidative stress too, actually. And then I'm also a fan of things like urolithin A, where it really does target mitophagy directly.

Hmm.

And you can get some endogenous urolithin A, like, you know, it's a byproduct of, like, things like walnuts and pomegranates from your gut. But I do think that oral supplementation can definitely And that's benefit everyone because it's like only 40% of people can actually create their own, like, urolithin A. So, and urolithin A, we know, helps with mitophagy within your cells. And I mean, there's, there's oral versions, there's topical versions, but that's something that I would certainly consider. I would also consider things like, you know, just polyphenols, whether it's through foods or through supplements. You know, there's decent data with EGCG, which is from green tea. Yeah.

Yeah.

As well as like, like cocoa flavanols. And then we, I mentioned carotenoids earlier, which include things like astaxanthin and beta-carotene. These all help kind of reduce that oxidative stress burden within your cells, which then will in turn help with mitophagy.

Astaxanthin is something that's in salmon because it's from the algae. It is.

Yes.

And it's like what the salmon eat that makes them orange.

Makes them orange. Right, right. I know some people—

It's like carrots.

It's like the same thing. Yeah, carrots. I know there's this trend with young people. It's called like tan maxing and they like are consuming all these like carrots and astaxanthin supplements so they could like look good.

I did that once. I wasn't intentionally, I decided carrot juice was good for me some way back when, and I was drinking carrot juice every day and I was like, wow, I'm like orange. It was crazy. I want to double-click on urolithin A. For people listening, it's what we call a postbiotic. So when you eat certain compounds, and these are polyphenols, it can be pomegranate, green tea, cranberry, walnuts, whatever. Your bacteria, if you have the right bacteria, will process that and create metabolites. And some of those metabolites have beneficial effects. So people don't understand that probably a third or half of the metabolites in their bloodstream are from their gut microbiome. They're not made by your cells. They're made by these bacteria that are producing all these molecules. And when you have bad bugs, they're producing bad crap. And when they have good bugs, they're producing these beneficial things.

Mm-hmm.

And so urolithinase, like you said, most people people don't have microbiome because, I mean, I give talks and I'm like, who here has never taken antibiotics? I have a room of 1,000 people. Like, nobody will raise their hand. Or like, I think once somebody raised their hand out of 1,000 people like, oh, I never drink antibiotics. But like, it's not very common. I mean, all of us have had antibiotics. We kind of kill off the bugs. And so it's really important to help to support that, those bugs. But also like, you can actually take a supplement, your L-theanine supplement. And it's something that actually I use every day.

Really?

Mostly from a metabolic function, from a brain function, from a muscle function, from mitophagy. I don't think about it for my skin so much, but now I do. And I think there's a lot of data on it. And one of the things it also does seems to do is reduce inflammation. So it can reduce CRP. It helps with all these benefits. So I think it's one of those supplements that has a lot of research. And I think, you know, there are millions and millions of dollars of research on this, which is not typical for most products. So I think I'm impressed by it. It's published in Journal of American Medical Association, major journals. It's not like in some supplement journal somewhere. It's good science.

Yeah.

So I think this phenomenon of taking care of your mitochondria as a concept is really important. Like, you're only as healthy as your mitochondria. And when you age, your mitochondria decline and function declines. And a lot of the things that we know for healthy aging, whether it's overnight log 12 to 14-hour fasts, or whether it's exercise, or whether it's, you know, you're 11, These are all things that help your mitochondria function better. So I think it's so important.

And with urolithin A too, I learned that you have to be cautious too with which products have urolithin A. There's really just that one, MitoPure, that has the properly studied amount or the accurate amount of urolithin A. Because if you look at some other brands, they've been studied with third-party testing where it doesn't actually show the adequate—

Yeah. The volume, the dose. The dose. Yeah. If you take 1 milligram of aspirin, it's not going to do anything. I agree. I, I, I, uh, I have been, um, a big fan of Timeline Nutrition and Mitopure for a long time. I've taken it for a long time. I think, you know, that's why they're one of the sponsors of my show. And I think, just to be transparent about it, I think it, you know, yes, they're, they're sponsoring the podcast, but also like, I, I looked at the science and you have, and I mean, you know, it makes sense and it, and it's, it's valid science and it, it's impressive compared, compared to a lot of other products that people take.

Yeah.

It's, it's impressive.

Yeah.

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There, there's definitely ways to modify your cellular function. I don't know if you're going to be 100%, you know, reversible, but like, you know, if somebody comes in, they're 70, we're not going to make them look like they're 25, but there are certainly— I know, I know. Right.

But 66, I was hoping for a miracle here.

I definitely think that we can for sure optimize cellular function, you know, regardless of how old you are.

And one of the things that sort of ties a little bit into, and I'm wondering if it ties into this, into mitochondria, is this exercise. And you said that muscle building is one of the best ways. It's a non-skin care intervention for healthier skin in midlife. And I don't really understand how strength training would affect the skin. Can you kind of unpack that for us?

I know. Yeah. I'm basing that off of, there is a study that was really interesting. It was a small study. It was like 60 or so participants. They were women in their kind of midlife age range, and they compared them doing aerobic exercise to strength training, and they both showed improvement with, like, hydration and barrier function in the skin. But they actually— and they were measuring, you know, different layers of the skin. The participants who were strength training actually had a thicker dermis, you know. So dermis is where our collagen sits.

Hmm.

And I think that it makes sense, you know, when you You know, when you're strength training, and I've heard you talk about this before, you're increasing, you're increasing insulin sensitivity. And then that kind of takes a load off of your cells. You're decreasing inflammation as well. Your mitochondria are optimally functioning. And when your cells in the dermis are affected by that, they're going to work better. They're going to build more collagen. So I, I, to me, it makes sense. I would like to see more studies, but, but I do really appreciate that.

I'm kind of on my face. Obviously I've had a lot of sun damage. And, but I noticed like I'm 66 and I look at my skin, the elasticity, and my body, it don't really have a lot of skin aging. I mean, I notice it's a little bit thinner in some ways, but I've been eating well my whole life. I've been exercising my whole life. I've been trying to— I mean, stress is another thing, but I've been taking basic nutritional supplements and I'm just kind of amazed at what you can do if you actually— actually take care of yourself and you do the right things. And it's something I think it's good to start early, but also you can start at any age and slow the process down. And I'm curious, like, from your perspective, like, what are the highest value interventions for people listening? Like, what are the things that, you know, for skin longevity, like, what are the highest target interventions?

The highest value. So yeah, I know we want to talk about how, what we can do from the inside out, but I do have to say sun protection is probably the biggest thing you can do.

The sunblock. Yeah.

Sunscreen. And like when you're outside, you know, try to minimize the time you're in, you're outside during like those peak UV hours, which is like between 10:00 AM and 2:00 PM, wearing sun protective clothing, hats, those all play a role. Now, I guess you need UV-blocking clothes, or you don't need it, but, but like, but sunscreen's not 100% gonna block out all your UV rays.

But can you, can you get like sun damage through your clothes?

Like, oh yeah, yeah, yeah. UV can still penetrate clothes. Not as, you know, it's still a form of protection, but, but UPF material does a much better job at like blocking out UV rays.

Yeah.

So, um, just some things to consider. And I know that we, you know, also, I just want to take into consideration the fact that the sun is really important too, right? Like for vitamin D absorption, metabolism, as well as like circadian rhythm regulation.

Yeah, for light in your eyes.

Definitely. Like getting that sun early in the morning. But I think that you can still do all those things. You can go outside, wear sunscreen. Don't try to— don't try not to bake outside for prolonged periods of time. That's where we— that's where we see a lot of the skin cancer. And, you know, with melanoma, it's for people who have that intermittent prolonged exposure. So it's interesting.

When you go to the Bahamas for a holiday and you lay on the beach all day for 7 days.

Exactly. For men, the most common location for melanoma is the back, and for women, it's the legs. But those aren't areas that are seeing the sun every day. But for, like, those intermittent bursts of sun exposure, like going to the Bahamas and you're just getting, like, burned on your back, that plays a bigger role with melanoma development. Whereas the non-melanoma skin cancers, like basal cell carcinoma or squamous cell carcinoma, those are from just, like, chronic daily sun exposure that just build up over time. But all of that can contribute to skin cancer development as well as accelerated aging.

But not all melanomas are skin sun exposure related, are they? Or are they?

Well, yeah, you're right. Not all, because we can see melanoma between the toes. We could see anal melanoma.

That's what I mean.

Yeah. So there's other components too. And what's interesting too, we have studies to show that low vitamin D can make melanoma, like can put you at higher risk for melanoma, which is kind of ironic, right? Because we say stay out of the sun to, you know, to prevent melanoma. So it's about finding that healthy balance. Vitamin D is important for melanoma prevention, too. And, you know, we always talk about supplementation and trying to get vitamin D through food. But like I said, you can still go outside. Just got to do it responsibly. But I'm sorry, to answer your question, the highest impact is sun protection.

Sun protection.

It is. And it's— I mean, we have studies to show that it plays the biggest role, probably about 80%, and when it comes to skin aging, there's genetics, but then, you know, there's other factors too. So smoking, we talked about, thankfully, you know, I think people aren't smoking as much. They— people still do smoke, of course, but that's huge. Like when they look at identical twin studies and like they see the twin who's out in the sun and smokes, drastic difference.

Yeah.

So that— and then when we talk about nutrition, so sugar can accelerate I've heard you talk about advanced glycation end products or AGEs.

Yeah.

This is when sugar, you know, when you have more sugar that can bind to your collagen fibers and that can make your collagen more brittle and like break down more easily and like not remodel as well.

Yeah.

So sugar is huge. And then of course, if you have insulin resistance from sugar, that's going to create more inflammation and further aggravate, you know, collagen breakdown. Try to like minimize processed foods as well. But most of our data is with sugar. And then when it comes to what to add, we touched on this briefly, but just like, just nutrient-dense foods, foods full of polyphenols. I just say like, just colorful foods, you know, like vitamin C, your citrus, your bell pepper, like the berries, just things that are full of polyphenols is important.

Mm-hmm.

And then, yeah, and we talked about carotenoids too, whether it's— and also lycopene, beta-carotene, as well as astaxanthin. And then sleep is huge. We do have some good data to show that poor sleep sleep, circadian rhythm disruption, that can all accelerate ageing. Stress is huge, and stress is harder to quantify just because what is stress? We all deal with so much stress. But just a matter of incorporating stress-decreasing modalities into your life. And then exercise, we have data to show that helps with skin collagen production. Those would— and minimizing pollution. I would say those So those are like the biggest levers with sun protection being the biggest one. And then we also have a ton of evidence when it— if you just put it in a vacuum, like if it's just— if you're just focusing on skin, topical retinoids, we have decades of studies to show the impact of topical retinoids for skin health.

It's like a vitamin A derivative.

Vitamin A derivative. Yeah. So the most popular example is retinol, which you can get over the counter. Then there's a prescription retinoid, which is tretinoin. The brand name is Retin-A. Those are the most common forms. There's retinal, retinaldehyde, there's tazarotene, adapalene. There's a lot. But anyways, there's a lot of studies to show that that really helps with collagen remodeling. And then topical antioxidants, vitamin C being the most studied example, shows. So after sunscreen, we like retinoids and vitamin C.

So put vitamin C and retinoids on your skin.

Correct. Yeah, yeah. Vitamin C in the morning because that works alongside sunscreen to help with like the oxidative stress from the sun as well as pollution. And then retinoids at night to really contribute to that repair process, Okay.

I need to up my game here because I've been focusing on my exercise and diet and skincare. I'm like, ah, I'm a guy. I don't really care.

I mean, if you want to, for overall longevity, you got to do all the exercise, the diet. That's going to be better for overall longevity.

I'm curious about, I don't want my skin to age faster than it needs to. And these seem like simple things, like the vitamin C and retinoids. And you can do the retinol over the counter?

You can do retinol over the counter.

Is that strong enough?

Yeah. For a lot of people it is. And the thing The thing is, it's just slower acting. Tretinoin is faster acting. Your retinol has to get converted. It has to go through a couple of stages before it gets converted to tretinoin. So tretinoin works faster. It has a higher irritation potential. So people who have sensitive skin or are just starting out, we do recommend something like a retinol. Yeah. And I would say we have the most evidence behind that. I know Timeline has their topical— like you could do topical urolithin A.

Yeah.

Which we do have some studies to show that that can help. with wrinkle reduction as well as increasing hydration and barrier repair in the skin. And so, yeah, something else to think about too. There's some supportive ingredients in those products, like there's topical niacinamide. We do have some nice data with topical niacinamide for barrier repair and wrinkles too, as well as, you know, things like hyaluronic acid, ceramides. These are like nice hydrating ingredients.

Great. And it's a good list. It's a good list of how to keep your skin healthy. Now, people are talking about— I just kind of briefly want to kind of dive into this, but people are talking talking about a lot of these sort of newer therapies, whether it's exosomes, peptides, growth factors, NAD products, red light therapy. Can you kind of— is it hype? Is it science? Like, what's the 80/20 on this stuff?

Yeah, I know people talk about those a lot. I would say don't do that unless you're already doing sunscreen, retinoids, vitamin C. But yes, growth factors.

And lifestyle.

And all the lifestyle things that we talked about. But yeah, I guess we'll talk about peptides because so many people— that word is just so popular, mainly because of the injectable peptides. But because the injectable peptides have become so popular, topical peptides is just gaining so much more buzz, but they've been around for decades too. And there are a bunch of different types of topical peptides. Some are better than others, but in general, I am definitely a fan. I think it's so easy to incorporate peptides into your routine. There's a lot of moisturizers that incorporate it, a lot of serums that already have it. There's even some in some sunscreens, but basically they send signals to your cells to build more collagen, or they send signals to your cells to increase hydration. So definitely all about peptides.

Like topically or like internally? Topically, because like GHK-Cu is a thing a lot of women are using for their skin.

And right, right.

Is that, is that like legit or?

I'm sure it helps, but as of now we don't have the evidence or like the safety measures in place to fully recommend it. Like, yeah. So I'll say that. But we do have topical GHK-Cu, the topical copper peptides, which we definitely have good evidence for. I mean, not as good as retinoids for sure, but that helps with collagen recycling and rebuilding. So incorporating copper peptides is wonderful into your routine, as well as some other like hydrating peptides and collagen-building peptides. And there's also like neuromodulating peptides. So some people like to call it like Botox in a bottle because, you know, Botox essentially like paralyzes your muscles. So you're not creating those deeper contractions. Super mild form of that with these neuropeptides for people who are like Botox averse. It doesn't compare to Botox. But anyways, so that's peptides. It does, depending on the peptide, you could do a lot of different functions in the skin. factors you mentioned. Growth factors are also signaling molecules that I think we do have some pretty decent evidence for. Growth factors are pretty large molecules. So, so just because you're putting growth factors on your skin does not necessarily mean it's penetrating the skin and doing its thing. So I would say you have to make sure you get the right growth factors. Not all of them are equal, but we— I do like them. And then there's PDRN, which has gained a lot of buzz because of the whole K-beauty, Korean beauty kind of—

What is PDRN?

So PDRN stands for Polydeoxyribonucleotide, and it's derived from salmon sperm.

Okay.

And most of the data is with PDRN injections into the skin. We, we know that it helps with collagen remodeling when it, when it gets into the dermal layer, it helps with wound healing. Topical PDRN, we have some evidence for its efficacy, but doesn't compare as much to the injectables. But I, I, I like it. I think it's a wonderful ingredient to have in your moisturizer. So, and we're seeing more of that.

Salmon sperm.

Salmon sperm. Salmon sperm facials is what we're calling it. Love that.

What about things like exosomes and stem cells? Like people are injecting those in their face topically.

Once again, it's one of those areas where it's a little bit controversial because we do still need more safety data. I think it's still kind of the wild, wild west with that. There are a lot of products out there that have topical exosomes in them and they are lovely and they seem to work, but whether or not the exosomes are doing anything or what exactly they're doing, it's hard to say because it's so hard to stabilize exosomes at room temperature. Like they need to be like frozen at a negative temperature.

creams or—

yeah. And also it's like, what exosomes are the best? Like umbilical cord exosomes or like mesenchymal exosomes from bone marrow or like fat cells? Yeah, there's different kinds. And that kind of goes along with stem cells too, you know, which ones are the best? So I think we still have more to come with that, but I think it's promising.

I know you've been a dermatologist for a long time. I can't tell how old you are. I want to know what your skin routine looks like. Okay.

Wait, wait. Should I have you guess how old I am?

I kind of would say like maybe late 30s.

Yeah, I'm 43.

Yeah.

So that I'll, I'll take that. Thank you. But yeah, so, you know, I mentioned the topical skincare regimen. I definitely for a while have been incorporating sunscreen. I didn't for most of my 20s and it wasn't until I started during residency where I was like, oh, okay, I guess I should do this. Um, so I do sunscreen, I do some type of brightening retinoid at night. By the way, you can't use a retinoid when you're pregnant. And then, um, I do vitamin C in the morning. But I do, I use, I use serums and, and moisturizers that incorporate peptides and/or growth factors. I do use a product with PDRN and copper peptides. I use a serum that has a neuromodulating peptide to help soften my lines.

Do these things stack? You just put one on after the other?

So, okay, you— so it's It's funny because I, I hate overwhelming people because there's so much noise out there in the skincare world. So what I tell people is really the, the foundational skincare regimen is a cleanser because like washing your face is important too. It's kind of underrated.

I never do that.

The buildup of pollution, like all that stuff during the day, like that accelerates skin aging. Those are— those creates oxidative stress on your skin. So washing your face is so important. And then moisturizing because once again, because of the elements, our skin barrier is disrupted. Our keratinocytes are working hard. to repair the barrier. And like, if there's stress on our skin, it needs help. So moisturizer is important, and then sunscreen. So those are the 3 minimal things to do. And then after that, a retinoid and vitamin C. And then if that's well established, then you can incorporate another serum that might have like peptides or growth factors. And then like, just find a good moisturizer that has all the fun things, that has growth factors and peptides too.

Yeah, that's good. I mean, just kind of a brief aside, because I think this is an issue for for me, I think about this, which is what's in the skincare products besides the active ingredients, and are those harmful? And I had a patient once who used sunblock all the time. When I checked her urine, she had extremely high levels of parabens, which is a plastic, like a petrochemical toxin that they use in these compounds. So are you fixing one thing and hurting another thing? And how do you manage that?

Yeah.

And what do you think of the Skin Deep database from Environmental Working Group that kind of grades skincare products based on levels of toxins in them?

I respect the fact that something like this exists out there. I do take it with a grain of salt because the data that's in the EWG database is from studies where there are usually like insanely, almost impractical doses, insanely high amounts of these products or ingredients that are used on animal models. And we can see issues in animal models, whether it's endocrine disrupting issues, potentially cancer, you know? And it's hard to extrapolate that to human data for a lot of these things, for things like parabens and even some of these chemical sunscreens too. And so I think theoretically it seems scary, like, oh my God, when it's given in insanely high doses to animals, like, we should not do that. We shouldn't use it as humans. But I wouldn't— you know, if people have been using a lot of these products, I wouldn't freak out. Like, just because somebody has a bunch of parabens in their urine, the question is, okay, what— but what exactly— like, what is— how is that manifesting in their skin?

I mean, my philosophy is— and maybe this is right or wrong, I don't know— but if you wouldn't eat it, don't put it on your skin, because everything you put on your skin gets Okay, so I have something to say to that.

I have something to say to that because our skin is— honestly, our skin does serve as a great barrier. Like, it's one of the functions of the skin is to protect our, our body from like the outside elements, from pathogens, from irritants and all those things. So there is an element of really good barrier protection on the skin. But the other thing I want to add too is that not necessarily everything you eat is good for your skin.

This is true.

Like lemon. Like lemon will destroy your skin.

Really?

Yes.

Lemon juice?

Lemon juice? Yeah. Lemon can cause like irritation from the acids in it. in the skin. I mean, we have stomach acids that can, that can deal with that.

Putting lemon on your skin or eating lemon?

So eating lemon is good. Oh, even putting lemon on your skin is not good.

I wouldn't do that. Okay.

Yeah. Yeah.

So, so there's like, so, but yes, you want to put chili peppers on your face, you know?

Right, exactly, exactly. But no, but I, I do appreciate you saying that. Like, we have to be, you know, if we can eat it, like, then, you know, it's potentially safe for our skin. But I, I also want people to know that our skin is there to protect us too. And like, a lot of these things usually just penetrate through the epidermis, not really getting into our vasculature. Of course, there's things that get into our vasculature as well, but our skin, I would give it more credit. It really does do a good job at keeping a lot of the things out. I'll say that. I'll say that. But, but yes, there are definitely things that, that can get absorbed that aren't.

I mean, because I always wonder about it, because as a doctor, I'm like, when someone comes to the emergency room, they have a heart attack, you put nitroglycerin paste on their chest.

Yeah.

There's topical estrogen. Topical hormones. You've got, you know, all these Topical drugs that we deliver through the skin, whether it's fentanyl patches or like, it's a known thing.

It is a known thing.

Yes. So like, it's not like they don't get through.

No, for sure. And there's certain vehicles that deliver these things more effectively than others. Um, so, so it's, it's a matter of like what the product is, but yeah, no, for sure. Like things definitely can get absorbed through the skin.

So if you have a choice between something that doesn't have a lot of bad industrial ingredients in it Or something that does, would you choose the one that doesn't, or you don't care?

Of course I would want to look at the safety data behind it too, but, but I would try to minimize like anything that has this like toxic burden to the skin for sure. Yeah.

Okay, good. I think you're right. There's probably not enough data. Like what happens when you put all these things on, but like, just like at a high level, like I wonder if anybody's done the studies to see if you put this stuff on your skin and measure the blood levels or urine levels of these compounds. Has anybody done that work?

Yeah. I mean, I think that, that some of it has been looked at too. Like we, we do see higher absorption with chemical sunscreens in our bloodstream.

So is it better to use mineral sunscreen then?

So yeah, I mean, if that sort of freaks you out, then yes, I would use mineral sunscreen. The FDA kind of puts that in the category of generally recognized as safe, whereas the chemical sunscreen is not in that category, mainly because you do have extensive systemic absorption with it. Whether or not that does anything is just still up for debate. So—

Wait, are you saying that the FDA The FDA says that these chemical sunscreens are not generally recognized as safe?

That's right.

Wow.

But there's a new one that just came out this past year that is— it's BEMT, ParsolShield is another name for it— that is, it's a chemical sunscreen that is lumped with generally recognized as safe. But yeah, no, we need some work with the chemical sunscreens. But I have to tell people, they're still effective. They're still overall safe. We don't have the human data to show that it does anything, but it does absorb more into your bloodstream.

This is such a great conversation. Are you up for a few rapid-fire questions? Let's do it.

Okay.

So what's the biggest driver of premature skin aging?

UV radiation.

Sun.

Okay. Yeah, the sun.

Can you take aged skin and actually improve it or not?

Yes, you can. There's hope. There's hope.

What matters more for skin health? Is it, and longevity, skincare or exercise?

It depends on what your goals are. If you want to live longer, I would say exercise. If you want your skin to look smooth and wrinkle-free, skincare.

How about mitochondria? How important is it to skin health?

Oh, yeah. Mitochondria. Oh, at least a 9.

At least a 9.

Because there's a lot of other factors that also contribute to aging too. It's not just mitochondria. We need—

And urolithin A, is the data there or not?

Urolithin A is— yeah, I would say we have really good data with urolithin A.

Amazing. Okay. And then what's the most overrated anti-aging skincare trend?

Okay. So there's like products that are—

What TikTok trend should people be like, wait.

Oh wait, there's a couple of things. Like a lot of people are into like beef tallow and they think that that protects their skin from the sun. It's— no, it does not. It's an okay moisturizer, but it's not anything miraculous. We have a lot better moisturizers out there.

Beef fat. your skin, not a thing.

It's, it's, yeah, it's, it's, I don't even use coconut oil. It's like coconut oil can be helpful. It is comedogenic. So be careful if you're acne prone, but, but, um, beef tallow is also comedogenic as well, but people think it's like a miracle cure and it's not.

Amazing. Okay. Wow. Well, thank you so much, um, for your insights, your work, your, your advocacy, because there aren't enough, I would say, integrative functional dermatologists out there. Yeah, there really aren't. And, uh, I had the privilege of learning from some of the OG ones, you know, back in the day. And, and I think that, you know, if you're listening to this, you know, there's really 2 issues. One is healthy skin aging and 2 is skin conditions. And there's a lot to do about both of them.

Yeah.

And hopefully, you know, we can really help people to understand what they can do. Tell us where people can learn more about you, find you, learn about your work.

I am very active on social media. My handle is Dr. Mamina, Dr. M-A-M-I-N-A, on Instagram, TikTok, and YouTube. I have a website, drmamina.com. And if If you're also interested in prescription skincare, I'm a co-founder with other derms for a prescription skincare service called DermClick.

Amazing. DermClick. All right. Well, so good to meet you and have you on the podcast, and thanks for your work.

Thank you so much for having me.

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