We are Not Alone: The Skin Microbiome

Unlock the secrets of your skin with expert insights from Dr. Peter Lio, board certified dermatologist and Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University. Did you know billions of microorganisms live on your skin and that they could be the key to healthier, happier skin? We promise you'll gain a fresh perspective as we explore how these tiny life forms impact conditions like eczema and atopic dermatitis and learn about the latest breakthroughs in probiotic treatments that could revolutionize your skincare routine.

Topics include:

• Defining the skin microbiome and its components
• Individual uniqueness of each person's microbiome
• Consequences of microbiome imbalance and its role in skin conditions
• Information for maintaining a healthy microbiome
• How environmental factors affect the skin microbiome
• The relationship between diet, skin health, and the microbiome
• Understanding prebiotics and probiotics and their significance


For more information, check out the www.dermittrotter.com. 

Transcript

Understanding the Skin Microbiome and Health

Speaker 1 0:00

Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.

Speaker 2 0:18

Welcome to the Dermot Trotter Don't Swear About Skin Care podcast. I'd like to extend a warm welcome to my guest today, dr Peter Leo. He's a clinical assistant professor of dermatology and pediatrics at Northwestern University. He received his medical degree from Harvard Medical School and his dermatology training was also done at Harvard. While at Harvard he received formal training in acupuncture. A fun fact, dr Leo is the founding director of the Chicago Integrative Eczema Center, anda founding faculty member of the Integrative Dermatology Certificate Program, with over 400 publications and four textbooks. So, dr Leo, I'd really like to welcome you here to the podcast today.

Speaker 3 0:56

Thank you for having me. It's a great pleasure.

Speaker 2 0:59

Well, we are going to dive into a topic that I think is very interesting, because a lot of people have heard this term sort of thrown around the microbiome or the skin microbiome, and what does that really mean? So today we're going to talk more about this and get Dr Leo's perspective on this and how it really relates to skin health. So, first things first, can you really tell us you know what is the skin microbiome?

Speaker 3 1:24

It's crazy because we know that we are not alone. Even when you're sitting in a room quietly by yourself, you are not by yourself. We are surrounded by and filled with all of these different microorganisms, tiny bacteria, viruses and even little fungi that are all over and in our body, and it's really important because they, it turns out, are playing a huge role in keeping us healthy and strong and, in fact, if you mess with the microbiome, you learn very quickly that it is necessary for good health. It has to be in balance, and that's true in our gut, but also on our skin, where there are many, many, many different types of bacteria that are taking residence not only on the skin but even in our pores, and they are playing a role in keeping everything balanced, regulated and actually playing a very important role for our skin barrier, allowing it to be strong.

Speaker 2 2:09

You know it's kind of interesting. You say that because I think initially I used to think of the skin microbiome as like the freeloaders of the skin. You know they were just kind of hanging out doing nothing. But really what you just pointed out is it's not necessarily true. They're an essential part of our overall skin health, something that I find fascinating. You know, if you compared, maybe, your skin microbiome to mine, like, is everyone's the same or is there some variability in that, and what does that really mean?

Speaker 3 2:33

It's so fascinating because we're still learning a lot about it. But you're absolutely right, everyone is pretty unique and in fact you can talk about it almost like a fingerprint Every individual has their own. But what's even wilder is that, unlike a fingerprint, which more or less stays the same through your adult at least your adult life you know, little kid, maybe their fingers are going to change enough that it will be substantially different. But our microbiome changes a lot and you can make dramatic changes by what you're doing, including things like personal care products, so certain moisturizers, of course, using antibacterial soaps and cleansers, taking an antibiotic, putting a topical antibiotic on our skin, all of these things, swimming in the pool, sweating more certain hobbies. They can affect the signature of our microbiome over time, and both for good or for bad. A lot, I think, we still don't really understand, but we really do believe that it can make it unstable in certain situations.

Speaker 2 3:21

So if somebody's microbiome if you would call it, you know, unstable, what would you say that really means and what implications, you know, does that have down the line? Maybe for them to develop some sort of skin disease like eczema or atopic dermatitis?

Speaker 3 3:34

It's fascinating because we think about this idea of resilience that our microbiome is in a good place, it's balanced, it's doing its job, meaning both in terms of barrier function but also in terms of its metabolic function, it's playing a role in kind of even regulating some of the processes that are part of the healthy activity and physiology of the skin. And it's got resilience, it's pretty strong. So you might have some kind of an insult. Maybe you use a really harsh cleanser with antibacterial soap and your skin gets red and irritated and you're kind of itchy. And we know probably during that phase the microbiome looks different.

Speaker 3 4:05

The relative amounts of bacteria, which is sometimes measured as this bacterial diversity index sort of the amount of diversity in general, it turns out we want a very high diversity.

Speaker 3 4:14

There should be lots of different species. It starts to collapse down, we get fewer species and what we often see in times of stress is that one particular bad actor on the skin Staphylococcus aureus, staph goes up. So the diversity shuts down because Staph becomes more dominant and that can lead to a lot of problems. But that resilience means that after you get better, many times it goes back to normal or pretty much normal. But what we think is, if you push hard enough, if you keep irritating or keep damaging, you can then shift into a new normal. That is sort of a different balance that can often be much less healthy overall. So you can sort of have this resilience to a degree and then you can kind of push it into a new state that then becomes really stubborn. And I think that also helps us understand why some people are colonized with staph and no matter what we seem to do, we can't seem to get them back to normal. You can treat it over and over, but they keep going back to.

Speaker 2 5:09

So are there things that you recommend for people to work on getting that balance? Because it sounds like staph can definitely be a bully on the skin. It can kind of push things around and make it troubling to treat skin disease. What types of things? I know you mentioned moisturizers early on. Are there other types of things that you recommend for patients to maintain that proper balance of the microbiome or all those microorganisms living on our skin, living on our skin.

Speaker 3 5:30

It's the billion dollar question, because I think if we figure this out, we are going to be able to control more about health and disease than I think we've ever understood before. And, that being said, we're not there yet. So I think there's still a lot of speculation. What I'm going to say are some, I think, some general statements that, to some degree, I think we can back up with evidence. But even the best evidence I can give you is pretty sparse and I think we have a lot to learn.

Speaker 3 5:51

But the first thing is, I think your overall health is really important. So, eating properly, getting good sleep, taking good care of your general health that's important because we see patients with chronic illnesses, patients who are, you know, really broken down or beaten down their microbiome shifts. We know that with sleep deprivation, even just a single night of sleep deprivation, you can actually see a measurable change in your skin barrier and in your microbiome. Sleep deprivation, you can actually see a measurable change in your skin barrier and in your microbiome. So, taking care of yourself, as you'd imagine, step one, step two, our personal care products really do matter. So using more gentle products, keeping the skin moisturized, trying to avoid things that are harsh and irritating. I think that does matter, and you can again show, even on the order of weeks, different types of personal care routines can affect the skin barrier and can affect the microbiome. So those are all important. And then, finally, I think that if we have a problem on the skin, we really want to address it.

Speaker 3 6:38

So I meet a lot of families with atopic dermatitis. That's really my main focus of my career and it's fascinating. Many of them are very afraid of treatments. They're saying gosh, we just we don't want to use a lot of strong medicines, especially in little kids, and I understand, but I often say gosh. The truth is, though, we're in a dangerous spot. The skin is open and oozy and there's staph bacteria everywhere, and the microbiome is going crazy, both on the skin and in the gut, and I really feel like if we don't fix it, yes, in time they might get better A lot of kids do, but not all and in time it's possible that this will continue to worsen this vicious cycle of disease. So I really try to encourage people to do those things to get them better, so that we can get back to that healthy homeostasis and balanced set of conditions.

Speaker 2 7:19

You know it's kind of the. We talked a little bit about staph aureus. I mean being and I kind of teased a little bit of the bully where it'll take over. Are there other types of bacteria you feel like that are good or that we know have been beneficial for skin health, like that people might've heard of before, or organisms that you tell people you know it's good to have these also hanging out on the skin as well?

Skin Microbiome and Skin Health

Speaker 3 7:38

There are, and it's been interesting to see also the ones that we know about for the gut versus the skin, and they're a little bit different. So, for example, in the gut we many people have heard of lactobacillus and lactobacillus is kind of fascinating because it can be present in breast milk and and lactobacillus is kind of fascinating because it can be present in breast milk and we think that can be really healthy for the gut, especially developing gut, and there are many different strains of lactobacilli on the market. So what we found is that there is a signal that giving newborn babies that are at high risk of eczema if you give them oral lactobacillus, in particular the strain called lactobacillus rhamnosus GG, there is relatively convincing evidence that we can at least delay the onset of atopic dermatitis, if not actually prevent it to a small degree it's not overwhelming. I wish I could say it was a slam dunk, but it really does seem to be in some studies showing, yes, it delays it or prevents it in some patients. Other studies haven't shown that effect, although to my knowledge I haven't seen any studies show it caused trouble. So I really do encourage it. So when I have, especially, I have a family and I'm seeing the kid with pretty bad eczema and the mom comes in and is now expecting and says is there anything we can do for this child? I say, well, maybe if you start taking this and then as soon as the baby comes out, you also give it to them, that may help.

Speaker 3 8:56

So that different environments and so the bacteria on our skin are a little bit different. But what's interesting is we are finding that certain bacteria that's actually, it's derived from the soil, it's actually in the earth and it turns out that this nitrosomonas, which is a nitrogen fixing bacteria, right. So the way plants can actually fix nitrogen to make our food is they need bacteria. Again, part of this, this super organism idea that even a plant is not alone. It requires these little buddies in its microbiome to actually do what it needs to do. So there, this nitrosomonas helps fix nitrogen. It turns out that when we put it on our skin there is a signal that it actually helps our microbiome.

Speaker 3 9:43

There are others too. Rosiamonas is a different bacteria and that was studied at the National Institutes of Health and actually looked really promising. It was then purchased by a company and they took it further and it didn't quite pan out like they had hoped. But it's not dead now and over the counter company has it and has released it, and I actually have some patients who feel like it's making a difference. So it's one of these things where it's probably highly individualized.

Speaker 3 10:04

It's probably not as simple as one size fits all and I think that's why some of the companies looking into this are saying gosh, you know, this isn't helping everybody like we would want a drug to. You know, if you give somebody a, for example, an antibiotic, it should basically help everybody with the appropriate infection, and if it doesn't, you'd say there's a problem with the formulation or a problem with the drug. With this it's a little different. It seems like it's much more individualized.

Speaker 3 10:23

So part of the work that I've been involved in is looking at very specific combinations of strains that seem to have some synergy between them and then putting those onto the skin might give a very different result. But I would argue the highest level would be to look at each individual person's microbiome and then be able to build build a story about what are they missing, what's in balance, and then figure out how can we bolster them. But I have to say we're still in the very early days of this and all of that, as you can imagine, is super complicated and super expensive and highly variable because, as we said, it's a moving target. You know, depending on what they're doing that day, you can literally affect your microbiome in just a few days, depending on how you're, how you're actually treating it.

Speaker 2 11:00

I think that's so fascinating because you really see how dynamic it is. You know it's forever in flux or changing and I think you know trying to figure out what's the key to that consistency that provides like the optimal, you know, skin health for us and maybe also gut health, as it's tied together. You know, one of the things I'm curious about and again I don't know if there's a lot of data on this, but when you mentioned, it's so individual, you know, and depending upon where somebody may live you know a different country or part of the world do we feel like maybe those differences in microbiome makes sense as to why certain skin conditions are more prevalent in certain areas versus other places? Dr no-transcript.

Speaker 3 12:03

I didn't make this discovery. Let me be clear. I'd learned about it, but to me this was so exciting and it was that one of the key factors that can damage the microbiome is the environment, and it actually is a class of chemicals called diisocyanates, and this work was done by Ian Miles at National Institutes of Health and others. He has a group there. He's an allergist who's been focused on this and his point is often really exciting. He'll say you know, if you have a lake and you see some fish that have died, you might say, oh, what happened with these fish? Like, what's wrong with these fish? Do they have some problem? If you have a lake and most are dying, you'd say, what's wrong with this lake? Like something is bad here. And his point is that in the past, like 20, 30 years, we've seen such high numbers of kids and adults getting atopic dermatitis and having this dysbiosis. It's like something. It's not people anymore, it's not a genetic thing, it's not just them. There's something about our environment and one of the chemicals they've isolated is diisocyanates that are present in a lot of things, but in particular they're also present in wildfire smoke and it turns out there was a huge uptick in new onset adult atopic dermatitis for people that were exposed to, like the California and the Canadian wildfire smoke. So there may be things extrinsic to us that are damaging our microbiome.

Speaker 3 13:09

Another thing is detergents. So our clothes. You know we're very clean, we wash our clothes all the time and then we put them on and there can be residual detergent. Well, the microbiome and the skin barrier they work hand in hand, so this can damage them and upset that balance. Of course, all the exposure to antibiotics doesn't help. Even microplastics affect us. And then from our gut, when we're eating a lot of processed foods, they have these emulsifiers, and emulsifier is really just a fancy word for detergent as well. It's a kind of soap in a way, and that's damaging our gut microbiome, which of course has effects.

Speaker 3 13:39

You know, if we track our skin around, it's skin, skin, skin, skin, skin, gut. As soon as you turn the corner you're on your gut epithelia and the same thing for your respiratory skin, skin skin, skin, respiratory. They're all connected. These are all outside world blocks and barriers that we need. So really fascinating to see this story evolving and developing and learning that there may be key factors. That in one way, it's reassuring because it's out of our control. Obviously, again, we want to eat well, take care of ourselves, do these things to be kind to our skin, but some of it may be out of our control and we have to respond to that. We're living in a different world than our ancestors did, even 50 years ago.

Speaker 2 14:14

So what you're telling me and I just got from this if I live in California surrounded by these forest fires and I love my Thai detergent and I like to eat my Doritos, my skin is doomed. Is that what you're saying?

Speaker 3 14:24

So not necessarily, because that's the magic of this whole thing, that some people are really tough and they can just do okay in these environments, right, and we often say I'll sometimes have a family say we're doing everything, we're eating the best diet and we're using all this, why are we still miserable? And then you see the next person eating junk food and putting on highly fragrant stuff and doing facial scrubs and they're fine. So everyone is a little bit different, You're right. But but yes, I do think for that patient, for the patient who is pre predisposed or has a predilection for atopic dermatitis, they're going to be in big, big trouble.

Speaker 2 14:53

And that's important to highlight, because I think people do become obsessed with modifying all these factors with their lifestyle or changes and you know, think, well, I'm moving out of California and I'm giving up Doritos and forget using Thai detergent, and it doesn't make a difference. So I think that is really important to highlight the individuality of it. Like you said, genetic susceptibility, that everyone's going to be different, and so there are some of us that will still get away with enjoying some of those things, although maybe not so healthy, for other reasons as well. We talked a little bit, I know, about eczema and atopic derm, because that's obviously your area of focus. Are there other skin conditions where disruption in the microbiome we think maybe plays a role, like acne or other things like that too that we're learning more about?

Microbiome Dysbiosis in Skin and Gut

Speaker 3 15:32

Absolutely. I think the laser focus really is heading towards acne and rosacea. I think hydradenitis separativa is also a really important new target because if there is a microbiome issue and we can approach it, that would be fantastic for these patients because they suffer a lot. I think we see less of a signal in psoriasis. Interestingly, you would think there could still be some disruption. There probably is, but we don't see it as much. I think we can also see it in things like vaginal candidiasis. There's a signal there, people that especially get recurrent candidiasis.

Speaker 3 16:03

That's a form of dysbiosis there in many GI conditions as well. So, thinking about everything from irritable bowel but all the way up to things like ulcerative colitis and Crohn's disease, they probably have some significant dysbiosis. The other piece, interestingly from a dermatology standpoint, is alopecia areata. We had this case a couple of years ago. Really nice young guy had alopecia universalis, right, so total scalp, but also eyebrows, eyelashes, all body hair and also had Crohn's disease. He got a fecal transplant for his Crohn's, where they are, you know. I guess they take healthy stool or at least they extract the good bacteria from it. There are some details that I don't fully understand. Then they put them in and he regrew almost all of his hair. So that suggests the gut microbiome imbalance can affect our skin and even our hair, which is pretty exciting and obviously it's just a case report we don't have a big study on it but it was really, really intriguing.

Speaker 2 17:03

Yeah, I think that's fascinating. Fascinating because I have read some data, you know, just talking about that gut, skin access, you know kind of connection, or where you know you have a poor diet and it can give you bad skin potentially or it can interfere with, obviously, skin disease. And then I think people are, you know, are really surprised that you know something wrong with the skin microbiome. Could it really affect the GI system or cause diarrhea. I mean, some people feel like that's completely, you know, just out of you know the possibilities.

Speaker 2 17:22

But I was reading recently people think that there is some sort of crosstalk, you know, between sort of that skin and gut access, where I think there is that relationship. So I think that's really fascinating where you're seeing that and the idea of a fecal transplant. I can't imagine getting trained or you know, popping out and doing that, maybe as dermatologists but referring people. I think that's just fascinating to see where that connection can exist. You know, when you talk about treatments too, I mean you know this idea of kind of modifying and we talked about moisturization, things like that what are your thoughts on? You know, pre versus, like probiotics First, if you don't mind explaining just the difference between the two and other particular ones. You think that there are evidence, and maybe not necessarily just even brands, but I think you mentioned some of the bacteria early or that you would recommend potentially for patients that might help restore that balance.

Speaker 3 18:06

For sure. So absolutely, the terms are a little slippery too, but a probiotic really refers to a healthy, viable bacteria, like that's truly bacteria, that's ready to try to repopulate or do its thing. A prebiotic usually refers to like the food that would feed or kind of help encourage and support the good bacteria. Typically these are like oligosaccharides or kind of fibers. You can get a lot of it by eating a big fiber diet, a lot of non-soluble fibers, which is fascinating. And then of course we have host biotics, which are the dead bacteria. So many times they can, you can take the good bacteria and you kind of spin them down, break them down, and there's still have some of the products that they've made that can still be helpful. So the reason they're helping they have some of that in there. So they call that postbiotics or sometimes metabolomics, the products themselves and all of these things come together. We can also have symbiototics, putting the prebiotics and the probiotics together so that they kind of have some synergy, and I would just say that it's kind of overwhelming. There are so many different products on the market many, many orals, supplements, you know of combinations and a number of different topicals and a whole bunch in the pipeline. My sense is that there is not overwhelming data for that many of them on an individual level, and this makes my job tough, our job tough, and we have to. You know, when it comes down to the patient visit. Well, which one should I use? What do you recommend? And I would say that my general recommendation for an oral probiotic supplement is one that has multiple mixed strains, and there's a couple of different ones out there that I think kind of meet my criteria. But I'm looking in particular for ones that have lactobacillus strains or a couple of different types that I like like. Lactobacillus strains are a couple of different types that I like, like Lactobacillus fermentum and salivarius. There are a few like that. So if we can find something that has those strains we know is good quality, we know it has a good quality control and good manufacturing practices, that I think can be helpful. And of course they'll come in different types. You can get a capsule for an adult, you can get drops for little kids, you can get gummies for the older kids who might not want to swallow a pill, and then, I think, for the skin I'm sort of holding right now. Again, there's a couple of companies that are working on it right now, but I generally don't recommend anything.

Speaker 3 20:06

I will say that Rosiamona spray was now put out over the counter, but it's like over a hundred dollars for it. So it's very expensive and I've had a few patients try it. I've gotten some good feedback, but I still feel like the jury's out before we put that first and foremost. But for patients who are looking for it, if you Google Rosamonis topical spray it will come up and then they can order it and it's available without a prescription. You can certainly try it. But I would just caution people to just not jump into it because it's so expensive and then there are some restrictions on what you can use on your skin when you do this. So that's the other problem.

Speaker 3 20:41

When I was involved in the trial for the nitrosomonas study and there's more work on that happening right now as we speak, but as we were in that trial, we quickly realized that basically all the general soaps and moisturizers just killed it. They just were not compatible. So we ended up having patients just use pure squalane oil, which you can get. It's very mild and it kind of approximates our normal skin lipids nicely. So that was kind of a different twist on the whole thing to see that from a very functional approach. So it's not just as easy as squirting something on our skin or just taking one of the capsules. I think we're going to need something a little bit more, but that's kind of how I approach it right now.

Speaker 2 21:13

And I've got to ask cause? It is a bacteria. Does it have a fragrance or no fragrance? What does it smell like if you're spraying it on the skin?

Speaker 3 21:19

They smell just like nothing. There's no fragrance ever added to this stuff, but they just. It just looks like water yeah.

Speaker 2 21:25

Excellent, excellent, because I know those of me some of you out there are probably wondering if I'm spraying bacteria, what is this actually going to smell like? And, of course, for a lot of our folks with there to change those components or irritate your skin. So that's really good to know. I can't believe this time has just flown. This has been a fascinating conversation. I'm really just getting to touch on the surface of where we're headed with the microbiome and research. So thank you so much for sharing your expertise and knowledge on this topic, because I know people are hungry for this information and, just like you mentioned earlier, it's kind of scary to think about just the billions of organisms that are living on our skin. And you're right, we're definitely not alone. But you've shown us that we're not alone in the research and where this is headed. So we're going to make progress there. Dr Leo, for our listeners that want to find out more about you, where can they locate you? On social media or on the internet?

Speaker 3 22:11

The best place to find me is at chicagoeczemacom. That's our website where we put all the things we're working on and we have little support groups for eczema patients all over the world every other month. You're welcome to join. They're totally free. There's no. There's no sponsorship or anything. It's just us.

Speaker 2 22:26

Thank you so much for sharing and thank you again for coming on the podcast. Stay tuned for the next episode of Dermot Trotter. Don't swear about skincare.

Speaker 1 22:36

Thanks for listening to Dermot Trotter. For more about skincare, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.