Marc Serota Makes the Magic Happen: Eczema and Food Allergies Explained!

In this episode, Dr. Swanson talks to Dr. Marc Serota about everything from allergies to magic. Dr. Marc Serota is triple board-certified in dermatology, pediatrics, and allergy & immunology (bonus: he’s a magician, too). He practices in Littleton, Colorado. When you listen to this episode, you will learn about what’s behind food allergies, eczema, and the advances transforming pediatric allergy treatment today. Dr. Serota shares insights into immune system mysteries, early interventions,  most common food allergies in children (milk, eggs, peanuts, tree nuts, shellfish, soy, wheat, fish, and sesame) and how early exposure can actually build tolerance, lowering lifelong allergy risks. Dr. Sarota explains why certain foods like egg and milk tend to be outgrown, while nuts and shellfish often persist, and he also emphasizes the importance of accurate allergy diagnosis—reminding us that testing is just one piece of a bigger story. You’ll uncover the truth about false positives in allergy testing, the role of history in diagnosis, and why routine panels can mislead families. Plus, get expert strategies on managing eczema and food allergy relationships, including how cutting-edge biologics like Dupixent are revolutionizing early treatment. Join us for an exploration of how targeting immune pathways early could change the trajectory of allergic disease, plus practical tips on emergency epinephrine use, what’s been tested regarding expired EpiPens, and why aggressive early intervention isn’t just about skin—it's about shaping lifelong health. Whether you're a parent concerned about food allergies, a healthcare professional seeking the latest insights, or simply curious about how modern allergy science can alter futures, this episode is your guide. Tune in for a dose of medical mastery, magic tricks, and hope for healthier futures. 

Keywords

Dermatology, Allergies, Immunology, Dupixent, Allergist, Dermatologist, Pediatrician, Children, Pediatric, Peanuts, Epi Pen, Eczema, Rash, Milk Allergy, Egg Allergy, Tree Nut Allergy, Peanut Allergy, Shellfish Allergy, Soy Allergy, Wheat Allergy, Fish Allergy, Sesame Allergy, Food Intolerance, Food Avoidance

Chapters

00:00 Welcome and Introduction to Dr. Marc Serota

4:00 Magic in Vegas or Medicine? 

5:30 Soccer, College & Medical School in 6 Years 

7:15 Kansas City Chiefs, World Cup

8:00 Pediatrics, Dermatology, Allergy & Immunology 

9:00 The Big Nine Allergies

11:00 Most Common Signs of Allergies or Intolerance

13:00 Typical Timing for Reactions

14:00 Introducing Allergic Foods

16:30 Outgrowing Allergies 

18:00 High False Positive in Allergy Testing

20:00 Can Food Allergies be Passed Down

21:00 Oral Immunotherapy

23:00 Xolair

25:20 The Use of Epi Pens

28:00 Nasal Spray Neffy

29:00 Food Allergy & Eczema

32:45 Babies and Bloody Stools, Dairy Protein Sensitivity

36:00 Treatment of Eczema and Skin Barrier Repair

37:00 Atopic March: Eczema, Asthma, Allergies, EoE

39:20 Developing Immune Systems, Early Treatment

40:55 Helping Quality of Life & Development

43:00 Cumulative Life Course Impairment 

44:15 Fear About Treatments

49:30 Rapid Fire Round

54:55 Thank You & Goodbye 

The information shared on this podcast is for educational purposes only and is not a substitute for personalized medical advice. Always consult your  physician regarding your health.

Transcript

SPEAKER_00 0:04

Welcome to Skin Credible, where we tell you what you should know about skin and how to hello.

SPEAKER_01 0:16

Hello, everybody, and welcome to another fun-filled episode of Skin Credible Podcast. We're so thrilled to have you listening. You are in for a real treat today, you guys, because we have a fabulous guest. He is a pediatrician. He is an allergist. He is a dermatologist. He is a magician. And this, you guys, is Dr. Mark Sorota. Welcome, Mark. Welcome to the pod.

SPEAKER_02 0:45

Thanks for having me. And my favorite of those is magician for sure. So thank you for recognizing me.

SPEAKER_01 0:50

I mean, we we gotta talk about that. So, first of all, I know you through all of our work together in the dermatology universe, but the audience might not be familiar with you. Go ahead and tell everybody who you are. Who is Mark Sorota?

SPEAKER_02 1:05

Yeah, thanks so much for having me. So I started out after medical school doing a pediatrics residency and then an allergy immunology fellowship. And I was seeing so much skin disease during my allergy fellowship that it prompted me to then do a second residency in dermatology and become board certified in dermatology. So I practiced in dermatology and allergy immunology. And I also got interested in telemedicine. So I ended up founding a telemedicine company that helps power telemedicine brands all over the country, help patients access care. So a lot of different interests, but my first love was allergies and skin disease.

SPEAKER_01 1:38

And magic.

SPEAKER_02 1:39

And magic.

SPEAKER_01 1:41

How did you get into magic? Where did that fall in your training?

SPEAKER_02 1:45

I was actually on an airplane, and my brother's soccer coach was an amazing magician, and he showed me my first car trick, which I still do today and is an awesome trick. And I went up to the front of the plane and showed all the parents, and they were legitimately impressed that this, you know, 10-year-old showed them something they really couldn't understand. And I instantly was just like, I need to learn everything I can about magic. So that sparked a life, lifelong love. I've never performed a paid performance, but if you ever come to one of my lectures or anything like that, I usually usually finish with a trick if I can.

SPEAKER_01 2:15

I've seen it and it's amazing. And I don't know how you do it. And one day I would like to know. One day, when you retire from magic, I would like you to disclose all your secrets. You can come back on the pod and tell us how you do it all.

SPEAKER_02 2:27

Everybody should know one good magic trick. It really makes you stand out. And even just doing all those interviews for all those different specialties where you have to interview with lots of different people and they're trying to remember who everybody is, it just helps you stand out. So I think everybody should know one good magic trick.

SPEAKER_01 2:41

I love it. I love it. Yeah, they're like, oh, that was the that was the interviewee that did the magic for us, and you immediately are endeared to them. What's your do you like to do like sleight of hand magic? Isn't there like different kinds of magic? There's like sleight of hand, and then there's like, I don't know what the other kinds are.

SPEAKER_02 2:58

Yeah, I'd break it down into like three categories. One is like big stage illusions where you need lots of props and money to invest in special stage illusions. The second is called close-up magic or street magic, where you're doing things kind of one-on-one, close up to people, which includes cards and other things. And then the third type is called mentalism, where it's more the perception that you're able to read someone's mind or read their body language. You're not, there's always a trick involved. But those are the those are the three types. So big illusion, small illusion, or just pretending like you can get into your to their brain.

SPEAKER_01 3:32

Have you seen the movies Now You See Me? Or what's the what's the one about the magic with like Isla Fisher and the guy from the Facebook movie and Woody Harrelson?

SPEAKER_02 3:42

Yeah, Now You See Me, especially the first one, is a great movie. And there's a couple of real magic tricks that they really did perform in there. And even the ones where they didn't perform them, it's still kind of cool how they used movie magic to make it look like a real trick. So I definitely recommend that. And then if people are interested in another magic movie that's fantastic, it's called The Prestige. It's one of Christopher Nolan's like lesser-known movies, but it's Christian Bale, you Jackman, they're like competing, competing magicians at the turn of the century, and it's just like an awesome, really well done movie. So if you're into magic or you want to see a couple of good movies, those are two for sure.

SPEAKER_01 4:13

If you had an opportunity to have a show in Las Vegas, a magic show in Las Vegas, would you throw medicine away and just be like, I'm going to Vegas, I'm going to be an entertainer?

SPEAKER_02 4:26

I don't know if I would throw it completely away. I think something about me is I really like the diversity where I'm interested in lots of different things. I'm not someone that can just like sit in a medical office every day, five days a week. But I definitely would do it for some specified period of time. And whenever I do a lecture, or if I see a patient and I do a trick for them and they say, you know, they they compliment me on the trick, it's always like they say, Oh, you should be a magician. I was like, Are you saying I'm a bad doctor or a good magician? So I I I I I try to be both, I would I would like to be both at the same time. So I'll I'll I'll check out your skin during the day and then do it, do your show after dinner uh in Vegas.

SPEAKER_01 5:01

Yeah. I love it. I love it. Well, I've I've seen you live doing it and it's fabulous and amazing. And one day I want you to disclose all your all your secrets. You are practicing as a dermatologist. You also do the tele stuff, which I think is really, really cool. Where are you in practice?

SPEAKER_02 5:16

So I practice in Littleton, Colorado, in private practice, mostly dermatology, and then a little bit of allergy mixed in as well.

SPEAKER_01 5:23

I love that. I love that. And then we read online that you play soccer.

SPEAKER_02 5:28

Yeah, growing up, I was I played a lot of soccer and was very competitive with soccer, played through college and part of med school. So I did a combined six-year college med school program. So instead of doing four years of college, four years of med school, you do six years altogether. Um, so I played soccer for that program for five of the six years. It's kind of like a mid-major Division I soccer program. So soccer was uh was my second job growing up, and then I played soccer and and did the college and med school thing. So still And so where do where is this where is this six-year program?

SPEAKER_01 6:00

I've never never heard of that. That's so cool. Where is that?

SPEAKER_02 6:03

The one I went to is called University of Missouri in Kansas City, UMKC. There is there's a bunch of them. A lot of them are geared towards if you know you want to do medicine early on in life, like out of high school, it's more of that like European model where you don't have to go through the whole normal process of four years of college and then figure it out kind of thing. Um so I know like Northwestern has one. There's a few in Ohio through Neo UCOM. Uh there's some in Philadelphia with Hahnemann, like Villanova, Drexel, Lehigh. They're they're scattered all over, but they are mainly geared towards residents of the state who they want to stay there and practice, usually like rural medicine. So they're trying to promote medical careers early on. I was an out of state student from New York, where they they took a lot less out of state than in-state, but they're great if you know you want to do medicine. So if people are listening and they have a child or someone that's looking into careers and they know they want to do medicine, it's a great avenue for that. You don't take the MCAT. So I never took the MCAT, don't know what's on it. Yeah, they they take your SAT or ACT scores, and then you're on a track to just go to medical school as long as you're maintaining your GPA and performing okay.

SPEAKER_01 7:12

And so are you a Kansas City Chiefs fan?

SPEAKER_02 7:15

I am. I I became a Chiefs fan before Taylor Swift said it was okay. So I know you're I know you're a fan, but I did precede, I did predate uh Taylor Swift and Chiefs Kingdom.

SPEAKER_01 7:26

You were a Chiefs fan before the Chiefs were really worth rooting for.

SPEAKER_02 7:30

Yeah. I went through I went through the lean years. So I feel like I can took a little enjoyment the past past decade or so.

SPEAKER_01 7:36

Yeah. And then being a soccer buff, do you call it football?

SPEAKER_02 7:40

Uh I mean I still I still call it soccer. I like watching American football more than, you know, like the Champions League or something. But you know, the World Cup's coming this summer. Yeah. You know, if you're if you're interested, that's definitely uh a cool thing to do. It was last in the US in 94 and I went to some games as a little kid, so now I get to take take my son to a few games. Uh if you get the chance, you should definitely do that.

SPEAKER_01 8:02

The most I've been into soccer is Ted Lasso.

SPEAKER_02 8:06

I mean, that's a good that's a good entry point. I think that's a good entry point.

SPEAKER_01 8:10

I liked it. I liked it. Well, we're so happy to have you on because your experience in your training, hey, it's a good thing that you did the combined college med school because it saved you a couple years. Because then you spent, if my math is right, about a billion years doing residency programs.

SPEAKER_02 8:27

I think I could have like became a brain surgeon and saved a couple years. I had a lot of interest and uh I did save a few years. When I graduated, when I graduated med school, I was 23 and I didn't really know what I wanted to do. So I was three years of pediatrics, two years of allergy, and then three more years of dermatology. So eight eight years total.

SPEAKER_01 8:45

Yes, that's that's quite impressive. And so your background and your experience and your knowledge base is really, really unique. And so when I was thinking about who do I want to have on to talk about food allergy, the relationship with eczema, the atopic march, and all those things, I could think of nobody but Dr. Mark Sorota. And so I'm so thrilled to have you on to tell our audience all about these things. So I wanted to start out with talking about food allergy in general. What are the most common food allergies in kids?

SPEAKER_02 9:14

So there's basically a list of foods that people should be familiar with with food allergies. It used to be the top eight foods. Now I think people think of the top nine, the big nine. So, in no particular order, it's milk, eggs, peanut, tree nut, shellfish, soy, wheat, fish, and sesame. Those are the big nine foods. And I separate peanut and tree nut because people get confused and just call them nuts. Peanuts are a legume. They're not directly related to tree nuts, but because they're prepared in the same areas of the kitchen or in packaging, we recommend just avoiding both and just lumping them together as nuts, but they're not actually the same group of foods. And in kids, milk, egg, peanut would be the top foods that you would want to know if your child was allergic.

SPEAKER_01 10:02

And if you're allergic to tree nuts, like so that's cashews, pistachios, almonds, those are all tree nuts.

SPEAKER_02 10:08

Yes.

SPEAKER_01 10:09

And so if you have an allergy to one of those, do you automatically have an allergy to all of them?

SPEAKER_02 10:13

You don't automatically have an allergy to all of them. There is a lot of cross-reactivity. So your immune system is identifying little sequences of the proteins that make up those nuts, and they're they look very similar and they're also frequently prepared together. Theoretically, though, if you knew that you were taking a pistachio right from nature and eating it and you had a walnut allergy, but not a pistachio allergy, there's a reasonably good chance you're not going to have a reaction to it, especially if you've been tested and you're negative for that other tree nut. But in practicality, once you're allergic to one tree nut, we just label you allergic to all of them because it's just too dangerous to mix and match them.

SPEAKER_01 10:52

Totally, totally understood. And then what are the most common signs of a food allergy? Like, is there anything, if a parent comes in and says, this happened after eating this food, when are you like? That sounds like a food allergy.

SPEAKER_02 11:07

So the word allergy means a lot of different things to different people. And I try to think about a classic allergic reaction that could potentially cause a serious, serious symptoms or death, anaphylaxis, versus you're intolerant to something. So someone, for example, could be lactose intolerant, and when they have milk, they get GI upset, diarrhea, gas, things like that. That's an intolerance, but it's not an allergy in the sense it's not going to cause a traditional allergic reaction that could kill you or cause the typical allergic symptoms. So when someone says they have an allergy, the symptoms you would want to look for to say, is that truly an allergy or some kind of an intolerance? Typically they surround, they involve itching, hives, swelling of the skin, swelling of the tongue or tingling or burning sensation of the tongue because it's that's the first place that your mucosa is contacting it. And then more systemic reactions would be concerning for laryngeal edema, so throat swelling, a potentially low blood pressure. The one people frequently forget, which gets them into trouble when they're having an allergic reaction to a food, is vomiting or even diarrhea, but usually more vomiting. So you can eat something and start vomiting and not realize you're actually having an allergic reaction. But if you have vomiting plus something, especially something like hives or tongue tingling or throat swelling, now you're in really big trouble and you need to get treatment really quickly. Think about local symptoms like hive, swelling, throat, tongue symptoms, and then more systemic symptoms like vomiting or cardiovascular changes like low blood pressure. And some people even some people even note the feeling of impending doom, especially if you're dropping your blood pressure. A lot of people report prior to like passing out from anaphylaxis, they'll say, I had this feeling of impending doom. So people actually kind of know their system is is overreacting.

SPEAKER_01 12:54

Shutting down. Impending doom, that sounds bad. I think if if I was feeling impending doom, I I would be, I would be pretty bummed about that. That doesn't sound that doesn't sound pleasant. There's also a time frame to these symptoms. Correct me if I'm wrong. Like typically these things will occur relatively quickly after you've eaten said food.

SPEAKER_02 13:11

Typically, there's a few minor exceptions, but in general, you want to think about 15 to 60 minutes after you eat the food. So if someone says I had an allergic reaction to a food that I ate yesterday, barring a few very rare exceptions, that's probably not what is causing your symptoms.

SPEAKER_01 13:29

Okay. Okay. Very good. And then when parents are thinking about introducing solid foods to their kiddos, which food to their little babies, which foods are like worth special thought and consideration? Peanut jumps to my mind, but is there anything parents should be like just a little bit cautious about? And how should they handle that? Should they, I've heard on the internet that some parents are like giving peanut butter to their babies in like the ER parking lot. Like just in case. What advice would you have for families?

SPEAKER_02 14:04

So the guidance used to be like, you know, our parents' generation was to hold off certain allergic foods until kids reach pre-specified ages. Now the guidance is actually basically don't put your kid in a bubble. The earlier that you are exposed to foods, the earlier your body starts to develop tolerance to them and realize these are not foreign substances I need to react to. And we have to remember the port of entry is important. So you actually have an immune system in your gut that is designed partially to develop tolerance to foods, because those are foreign substances you're putting in your body. So if it's going through your gut and exposing those immune cells, then your body learns those are things that you're eating that are you should be tolerant to and not create reactions to. Versus if the allergens are coming through a port of entry that's not typical, like the skin. So you have a little kid that's eating and their skin's all broken out from their eczema. Now those allergens are penetrating and exposing the immune system in places where they're essentially jumping the border and not using the usual port of entry. And then you can develop more sensitizations to those things. So the take-home point is expose your kids as early as possible to all of the different foods because your immune system will naturally build up tolerance. And we one quick example of that is in Israel, they give their kids little peanut snacks that like dissolve and they can eat them really early, like when they're still babies. And they have very low rates.

SPEAKER_01 15:28

Yeah. Yeah.

SPEAKER_02 15:29

And they have really low rates of uh peanut allergy as opposed to in the US, where we were restricting babies and little kids eating allergic foods. And we actually made the situation worse because now you're developing you're not developing tolerance early in life.

SPEAKER_01 15:44

That peanut study changed everything because it was like up until then, we were like, oh gosh, anything that we might be afraid of, let's hold off on until they're older. And then they did the peanut study with early introduction and found the marked reduction in the incidence of peanut allergy. And it just switched all of our thinking just 100%. We were like, oh my gosh, early introduction is really key.

SPEAKER_02 16:05

Yeah, that's that's always the recommendation unless there's a specific reason to avoid something. So if you've been diagnosed with a, you know, milk protein allergy or a peanut allergy or an egg allergy as a small child, then yes, you're gonna avoid it for some specified period of time and we're gonna check you over time to see if you've grown out of it. But as long as that's not the situation, you want to expose kids as early as possible.

SPEAKER_01 16:28

And then which foods are kids most likely to outgrow those allergies to? I've turned I've heard egg that like the majority of kids will outgrow an egg allergy. I've heard peanut has the lowest chance of outgrowing it. What are your thoughts on that?

SPEAKER_02 16:42

In general, the two I think of are egg and milk. So if you have egg and milk as a child, you're likely to grow out of those things as you develop and get older. Peanut and shellfish and tree nut to a certain extent are tend to be more persistent and more lifelong. But we still will check periodically every year, every couple of years, we'll check and see if you're still reactive because I've still had many patients that grew out of their uh peanut or shellfish allergy. And the other thing to consider is was their initial diagnosis of allergy correct? Because there's a lot of false positives with allergy testing. So, yes, you're unlikely to grow out of a peanut allergy, for example, but if you were inappropriately diagnosed in the first place, then all bets are off and we should actually challenge you to peanut and see if you can tolerate it.

SPEAKER_01 17:28

So it's kind of like in the movie Dumb and Dumber, so you're saying there's a chance. And then speaking of screening kids for food allergy, I see a lot of patients for eczema and they come in with a panel of blood testing for allergens. And you have taught me that the blood testing is like only accurate 50% of the time, especially if a kiddo has eczema, and that prick testing is really the way to go about it. Am I correct? Did I hear you right? What are your thoughts there?

SPEAKER_02 18:00

Um, food allergy testing in general has a high false positive rate. So the negative predictive value is good, meaning if the test is negative, it's very likely you're not allergic to that thing. Nothing's 100%, but you're pretty likely to not be allergic. If it's positive, though, there's a high false positive rate. It could be up to 50% of the time. And that could be on blood testing or on skin prick testing. And there's a number of factors that go into that. For example, a person who has eczema, those reference ranges you see on the lab test, you could just throw them right out the window. They're not relevant. There's separate reference ranges for patients specifically who have eczema. So you can get a lot of false positives. One, because you just get a lot of false positives, and two, because somebody misinterpreted what a positive should actually look like. We never diagnose a patient with a food allergy based off of an allergy test for these reasons. That's something that I think is frequently misunderstood in the medical community is we don't diagnose based on a test. We diagnose on the history and then the test confirms our suspicion. So if you have a high peanut test, but you've never been exposed to peanut, or you eat peanuts and you're totally fine when you eat them, it doesn't matter that the test is high because the tests are not always very reliable. So you take the history and you put it together with the testing, and then you decide: is it safe enough for me as a doctor to challenge this person with that food in my office? Or am I confident enough that they actually are truly allergic and we're gonna tell them to avoid that food? That decision is very impactful on someone's life, especially a child. If you officially label them as peanut allergic, there's a whole series of dominoes of things that happen at school and at birthday parties and at home, and it really is disruptive of the child's life. So you don't want to just willy-nilly do that if you actually haven't gone through the steps to say, yes, this child likely does have a allergy to that food.

SPEAKER_01 19:48

Yeah. I heard an allergist say once at a conference, food allergy is a clinical diagnosis. You hear a story, it sounds consistent with food allergy, you do the testing to confirm. And that's always really stuck with me.

SPEAKER_02 20:00

I totally agree with that. The testing is a data point that lets you make the decision, but I totally agree. That's a great way to put it.

SPEAKER_01 20:08

Yeah. Um, I often get the question like, if a parent has a food allergy, like the parent is allergic to peanut, does the child have a higher incidence of being allergic to the same food? Certainly the tendency to be allergic in atopic that runs in families. But can a specific allergy run in a family?

SPEAKER_02 20:28

No, you can't pass down a specific food allergy to your child. You cannot have the food in your house because you don't want it in the house because you're allergic to it. But people who are allergic are more likely to have children that have allergic problems in general. But you would never say, I'm allergic to shrimp, so my child cannot eat shrimp.

SPEAKER_01 20:47

Okay. Okay, okay. Because I find sometimes parents are really tentative with that and I didn't know. If I don't know anything, I don't say anything about it. So I have been mom's the word on that, but now I feel more educated. Oral immunotherapy. So oral immunotherapy is something where a kiddo typically goes to an allergist and is given like teeny little aliquots of the food they're allergic to to try to generate tolerance. And when appropriately done by an allergist, it can really be a life-saving, life-changing sort of thing. But I sometimes see in my community and other communities, I sometimes see some questionable practices, often by folks who aren't allergists, doing nonspecific oral immunotherapy where they have like these batches of things, batches of different substances that they're giving to these little kids. What are your thoughts on oral immunotherapy?

SPEAKER_02 21:37

So there's two basic concepts. One is oral immunotherapy and one is a graded oral challenge. A graded oral challenge is when I bring your child or your or a patient to the office and say, I don't believe that you're peanut allergic. The story didn't convince me. We're going to give you a little bit of peanut and then a little bit more, a little bit more. And when you get up to a full dose of peanut and you don't have a reaction, we're going to take that off your list. Oral immunotherapy is I believe. You're allergic to peanut, I'm going to give you little tiny amounts and increase it really slowly, just like you think of allergy shots, but it's orally, to try to get you to a tolerant level where you can tolerate a certain amount of that food protein without having an anaphylactic reaction. So the idea is that if you had an accidental injection, ingestion, like you ate a cookie and there was a little bit of peanut in the cookie and you didn't know, you wouldn't immediately have an anaphylactic reaction because you had done the oral immunotherapy. So when done properly, it can be a potentially life-saving measure. The issue with it is you have to take that food in indefinitely to maintain your tolerance. So once you get built up to I can eat one peanut every day, then you have to continue to eat one peanut every day or you're going to lose your tolerance. Now, there are FDA-approved versions of that for some foods like peanut, and there are what people call homebrew where they make it themselves. And allergists have been doing that for years. I would say if you're going to go down the road of oral immunotherapy, which is reasonable to do, you should do it with a board-certified allergist who knows how to mix these things up and is doing it for a living, as opposed to, you know, concoctions. And it should really be for a single food. Like if you're doing it for more than one food, that to me doesn't make a whole lot of sense. And if you're, if they're doing it in those kind of ways where it's multiple foods, or they're doing it in ways where you're not being properly monitored, I would question if what they're giving you is actually potent enough to develop the kind of tolerance you need to if you had an accidental exposure, you would be okay. So yes to oral immunotherapy, yes, the FDA-approved versions, probably to homebrews, especially for single food allergens with allergists, probably no for the other thing that you were describing, where there's probably a lot less data on that in general. And then lastly, there's an FDA-approved biologic medication called Zolar, where you can actually use that preventatively to hopefully prevent your body from being able to create an anaphylactic reaction if you were exposed to the food. So it's not like you're tolerant to the food. We're just suppressing the allergic cells from being able to make a response to it as well as they would have.

SPEAKER_01 24:07

And Zolar is approved down to 12 for hives. What is the age for food allergy? Is it lower?

SPEAKER_02 24:13

That's a good question. I want to say it's two, but I'd have to double check because they're constantly changing and I don't want to misspeak.

SPEAKER_01 24:19

Yeah, yeah. And for those of you listening, Zolar works by targeting IgE, which is the immunoglobulin that plays a crucial role in allergies. And so that's how it works to help kind of mediate or lower your sensitivities to these things so that you're not gonna, you know, have a full anaphylaxis if you have an accidental ingestion.

SPEAKER_02 24:39

So that can be a really for food allergy.

SPEAKER_01 24:43

Okay, good. And it's it's a shot, it's an SHOT, as I say. And in the little ones for that purpose, Mark, is it monthly?

SPEAKER_02 24:51

It's monthly. And to me, as a parent and as someone who's treated anaphylaxis patients, about 150 people every year in the US die from food allergic reactions that are very preventable. I would 100% want that from my child because God forbid they get they're at a friend's house, they're at school, what you just can't control it 100% of the time. You need to have an epinephrine on them, but if they've been getting the zolar injections, there's a much better chance they're gonna be able to survive that episode.

SPEAKER_01 25:19

And I've heard you talk about the use of epi pens in kids with allergies and adults with allergies to a food. You I heard you say the reason to give an epi pen or you want to give an epi pen when you think about giving the epi pen. If it crosses your mind, go ahead and give it.

SPEAKER_02 25:36

100%. That is my number one piece of advice, not just for physicians, but for parents or anyone who's food allergic or allergic to anything. If you're thinking about if you should be giving epinephrine, you should have just already given it. It lasts for three to five minutes. It's not gonna harm a person, it's gonna increase their heart rate for a second. But if they're actually an anaphylaxis, it's gonna save their life. So you're not gonna harm them and you could potentially save their life. The number one associated reason for somebody dying from an allergic reaction is delayed administration of epinephrine. So if people get epinephrine right away, they're much more likely to survive. What happens is the person, you know, the kid is having symptoms, they're having hives, they're having a little bit of swelling. The nurse in the school gives them Benadryl and says, you know, go sit in the office for a bit, see how you feel. Epinephrine first, and then ask questions later.

SPEAKER_01 26:27

Yeah. And are the expiration dates on the epi shots like would you ever use an epi shot past its ep expiration?

SPEAKER_02 26:34

Yes, I would totally ignore the expiration date. You can look at that after you give it, but they've actually done studies. They did studies in like uh they were like they were like stakes, you know, like muscle, like like pieces of meat, to see what the potency was. And I think five years past its expiration date, it still retained like 80% of its potency. So if you gave me the choice of unexpired epi or expired epi, I'll take the unexpired epi. If you give me the choice of expired epi or nothing, a hundred times out of a hundred, you're giving the expired epidephrine, very likely still gonna work.

SPEAKER_03 27:05

Yeah, yeah. Okay.

SPEAKER_02 27:06

I think that's very the other mistake I the other mistake people make, just to add on to it, is there's they come in a two-pack, and some parents think like, oh, that's like one for home, one for school or something. It's because the the reaction can outlast the effect of the epi. So that's why we always have two. So if the first one doesn't work after three to five minutes, uh, or if it wears off after three to five minutes, you're supposed to give the second one. So you're giving the first one, you're calling 911. And then if you need to, don't be shy about giving the second dose because some people are gonna need a second dose.

SPEAKER_01 27:33

Yeah, and that's an important point. You aren't like giving the epi shot and you're like, okay, let's go shopping. You're giving the epi while you arrange for prompt medical care.

SPEAKER_02 27:42

Yeah, the the best scenario is you call you give them the give the epi, call 911, and the ambulance arrives and they say, Why'd you call me? This person looks fine. Because it it does work that quickly. It really does. Like you inject it, you watch it go in, you usually it's at the outer part of your thighs where you inject it. So you're looking at the injection, making sure that it's there and you're doing it. And then when you take the injection away and you have a chance to look up at the person's face, they're gonna be very happy with you and they're gonna look a lot more normal than they looked when they were swollen. It works that quickly, it's pretty amazing.

SPEAKER_01 28:11

And I've heard the EpiPen, it's capable of like going through clothes. Like you don't have to like worry about undressing the location. Like you can go ahead and give it. Is that true?

SPEAKER_02 28:20

Yeah, it's designed to go through clothes, including like jeans and thicker clothes that people might be wearing with their pants. You shouldn't delay giving it, trying to get their clothes off if you can't.

SPEAKER_03 28:29

Right.

SPEAKER_02 28:29

The other thing to be aware of is there's a device called AudiQ that gives you audio instructions, kind of like a defibrillator, like tells you what to do. And there's also an FDA-approved nasal spray now that's not a shot. Yeah, so that's a and their their efficacy is essentially the same as the injection, which is pretty incredible. So I think as a doctor, I kind of like give me the shot. I know I got it in. I feel good about myself. But in reality, the nasal spray for most people would be a lot less intimidating, and maybe they would just give the medicine just that much quicker because it's it's just a nose spray.

SPEAKER_01 29:01

And it's such a cute name, Nephi. Yeah, like sometimes the FDA just nails those names, and Nephi is an example. It's like your cute little pet Nephi. It's super cute. So now let's talk about the relationship between food allergy and eczema, because this is something I encounter every single day in clinic. Parents wonder, families wonder. And so, as a dermatologist and an allergist and a pediatrician, what is your understanding of the relationship between food allergy and eczema as we understand it today? Because it's something that has evolved over time.

SPEAKER_02 29:30

It's been debated, and I think like minds can have differing opinions on this, but my understanding and what I believe is true, is food allergies can be associated with eczema. They are not the cause of your eczema. So patients who have eczema are more likely to have food allergies, probably because of the skin barrier dysfunction where allergens are coming in through the wrong port of entry. There's probably a genetic component where because these atopic diseases occur as a cluster as part of how your immune system develops. But you're not, you're never gonna say, if I just eliminate this food, my eczema is gonna go away. That being said, there are some patients, usually children, where if there's there, there's a certain food where if they eat that food, it will flare up their skin. And that's kind of what I call the mom diagnosis. It's like, I know my kid, and when my kid drinks milk, their eczema is gonna be a mess tomorrow. Okay, we're gonna test them for milk and we're gonna avoid milk for the time being. So, yes, there is a component where it could potentially flare existing eczema. Food food allergies will not cause you to have eczema, and removing foods from your diet will not make your eczema magically go away. It's a it's a genetic skin condition at its core.

SPEAKER_01 30:44

Well, and I learned from Dr. Anne-Marie Singh, who's an allergist in Wisconsin, that there's IgE-mediated food allergy, which causes the hives, the trouble breathing, the throwing up, the potential anaphylaxis. And then there's those rare circumstances where a child has food-driven eczema or the food makes their eczema worse. And that's mediated in a different immunologic process. And if you completely avoid the food that's triggering your eczema, it actually increases the likelihood that your child will develop the IgE-mediated food allergy, which is the much more serious of the two. Is this common knowledge in the allergy world, or is this a select opinion? What are your thoughts on that?

SPEAKER_02 31:29

Well, I think it's probably more of a select opinion, but I could see some validity in it. There are different subsets of allergy, meaning not all allergy is what you think of as you eat a peanut and 15 minutes later you get hives and you look like, you know, the movie hitch. There are other subtypes of allergies. So there's type four hypersensitivity or type four allergies where it's on contact and it's more of a delayed response. And there are certain types of patients where we actually do contact food testing for people. So there's a disease called eosinophilic esophagitis, where they actually react on their skin to different foods. And if you withdraw those foods, their GI symptoms get better. Um, there's also delayed type allergic reactions. Um, those can occur like there's one called alpha gal, you're probably familiar with, that involves um certain types of meat. And there's delayed type allergic reactions with wheat, which actually it's a weird one, where if you combine exercise and wheat, you get delayed allergic reactions later. So we don't know, we don't know everything that's going on with the immune system with every type of allergic reaction. So you always have to leave room for some of these outlier things because number one, we don't fully know those mechanisms. And number two, like the outliers kind of prove the rule. But in general, in general, it's more of the classical situation when it comes to traditional food allergy that we described.

SPEAKER_01 32:46

Typically see maybe like one or two patients a year, babies a year, babies under the age of one that have bad eczema, and then they tend to have like bloody or mucusy diarrhea. And it's my understanding that that can be a manifestation of a dairy protein allergy. Am I right on that?

SPEAKER_02 33:01

Yes. So that is milk protein-induced enterocolitis. Um, and there's a few other variations of that. But the short answer is yes. And if you have a baby that is having bloody stools, that's one of the things that's in the differential that you must consider is is a milk protein issue. And an allergist would help you figure that out. It's not the only thing that can cause that. And there are other serious things that can lead to bloody stools, but a baby with bloody stools needs to be evaluated and admitted to the hospital and worked up for what that could be.

SPEAKER_01 33:32

Yeah, yeah. And in a patient where you're not hearing a history suggestive of the IgE-mediated food allergy, you're not hearing anything suspicious for alpha-gal or the dairy protein sensitivity. If you're just kind of a kid with eczema, is eliminating foods typically health with No, I would not recommend that.

SPEAKER_02 33:53

And I think in some cases it can be harmful because it really limits some of their nutritional options that they have. So I don't advocate for food elimination diets for eczema. I also don't advocate for routine just panels of allergy testing, because not only did I say those can be false positive, not only did I say that eczema patients are gonna have a different reference range. So if you really don't know how to interpret them, it's gonna look positive. But because you have so much allergy protein floating around your blood, which we call it can indiscriminately bind things on the lab testing. And normally that would wash off. But if there's a lot of it, you can't wash all of it off. There's a lot of that in an eczema patient. So they could have falsely high results because of their very condition that they have eczema. So I would do very targeted testing based on the history, only when the clinical diagnosis warranted it.

SPEAKER_01 34:41

I often have parents, I bet you do too, that want to try to avoid foods because they want to get to the root of the eczema. I usually tell them, like, I wish it were that simple. I wish I could tell you to just avoid this or avoid that, and it would just magically cure your baby's eczema so many times, the overwhelming majority of the times, that is not the case. How do you in your clinic handle that question?

SPEAKER_02 35:07

Largely the same to what you said. I say eczema is a genetic skin condition. Your skin, the skin has a mutation where the proteins in the skin don't hold on to water well, which results in skin barrier dysfunction and everything that comes along with that. So you didn't do something to cause this, and we're not gonna remove something to take it away. It's a genetic skin condition. The good news is about 50% of kids are gonna grow out of this condition as they get into adults. The bad news is I don't know how to predict that. I can't tell you if your child's gonna be in the 50% that will or the 50% that won't. But if there's a strong family history, it's a little more suggestive they're gonna grow up to still have eczema. And the great news is we have many different amazing treatments for eczema now. So even if you're in the group that's going to have it for your life, it doesn't mean you actually have to have it for your life. You're gonna forget you have it. It's just gonna be there in the background.

SPEAKER_01 36:00

Yeah. And you alluded to a little bit earlier, for years and years, people have tried to blame eczema on a food. And now we're realizing that eczema might be the cause of food allergy because those food particles are able to enter through the skin's broken barrier, triggering the abnormal immunologic response, which becomes allergy. And we believe that good treatment of the eczema can actually help minimize the risk for food allergies. Any additional comments on that?

SPEAKER_02 36:28

I think we're just learning more and more about this port of entry issue. And if you repair the skin barrier, that you're not exposing the immune system in places that it's not used to seeing these substances. So that's probably one part of it. Another part is trying to prevent the atopic march, meaning a lot of children start with eczema, go on to have asthma, go on to have allergies. So can we actually shut off that march where we're telling the immune system to stand down? And we've done that for years with allergy immunotherapy, with allergy shots. We know that that helps prevent the atopic march. And then some of these newer treatments that we have, not so new anymore, biologics like dupixant, we're starting them now as young as six months. So the hope is that we'll be able to affect the same kind of thing where by turning down those immune responses, they're not going to go on to have other diseases that are frankly, some of them are harder to treat than eczema is sometimes. Asthma could be a worse problem for the person in their skin. So if we can prevent them from developing asthma down the road by treating their skin, that's kind of a no-brainer. You're doing both things.

SPEAKER_01 37:29

Yeah, yeah. And you're reading my mind because that's what I wanted to turn to next is the atopic march. And so for those of you listening that might not be aware, we know that certain conditions tend to occur together. Eczema, allergies, asthma, EOE, eosinophilic esophagitis is something that's emerged in the past several years as well. And eczema tends to be kind of the first step in this process. And then the kids go on to have food allergy, nasal allergies, asthma, EOE, et cetera. And we have some data now for dupixant being approved onto the age of six months old, that we can even intervene early for the eczema and reduce the risk of food allergy and asthma. And I find that really, really important and cool. As an allergist, dermatologist, Mark Sarota, your two cents.

SPEAKER_02 38:16

Yeah, it's really encouraging that we can affect change like that at such a young age. When you're talking to a six-month-old parents about, hey, I'm gonna put your child on an injection once a month indefinitely. We're gonna clear up their skin, but sometimes they need a little bit extra motivation as to why is my six-month-old deserved to be on injections. Well, I want to prevent, I don't, I don't even want to know which, which uh, you know, 50% of my patients are gonna go on to develop another atopic comorbidity. So if you can actually shut up that process early, that's really, that's really exciting. And I think the proposed mechanism for doing that is it's targeting a really central part of your allergic immune system called the TH2 cell. So the naive T cell is differentiating into the allergic cell general, and that is the quarterback for a lot of allergic problems. So if we can stop that signaling process, then we can effectuate not just their eczema getting better, but all of these other atopic diseases. And that's why dupixin has all these different indications beyond just eczema, um, things like asthma, eosinophilic esophagitis, you mentioned. And being able to turn off that atopic march early makes sense if you're targeting that quarterback of this whole process.

SPEAKER_01 39:26

One thing we don't know is like just how early we need to intervene in order to see these benefits. Knowing what you know about immunology, do you have a best guess? Like, do you think it's best to introduce it before age two, before age five? When potentially has that ship sailed? Where's our window of opportunity?

SPEAKER_02 39:47

We don't know exactly. I would say a universal truth when it comes to the developing immune system, which begins in utero and progresses throughout your entire life. The earlier you do it, the probably better off you are. Because once you actually allow cells that are not tolerant to either your own self-proteins, which causes autoimmunity, or they're or they're not tolerant to normally occurring things in your environment like allergens, it's very difficult to put that genie back in the bottle and say, I don't want those cells circulating in my body anymore because they're reacting to stuff they should be reacting to. So the earlier you develop that tolerance, the better off you probably are. I would say I think of different breakpoints in development. And probably for me, before the age of six is a critical break point. And then as early as possible before that, if you can do it in the baby stage under the age of two, let's say, that would be the most helpful. But before six, I think would be useful. After the age of six, I think you probably start to lose a significant amount of the benefit of trying to prevent that march because it's probably already starting to some degree.

SPEAKER_01 40:52

On a somewhat related note, I wanted to get your two cents because I've had an inkling being a pediatric dermatologist treating all these kids with dupixant and seeing a little bit of the data that's starting to emerge. I kind of feel like early use of dupixant even helps the kids outgrow their eczema. And so people are starting to throw around the word like disease mitigation. Like, does it affect the trajectory of the disease? Do you have any thoughts on that, being much smarter than I am about the immunology of it all?

SPEAKER_02 41:26

I don't know if that's true, but I think I think largely I agree with that statement. I think you're effectuating tolerance early on. And the other thing I try to impress upon not just parents but physicians who are treating these patients is think of this not just as a skin disease, but as a critical quality of life disease. It's a developmental problem in a little kid. You know, we check their eyes, we check their hearing right when they're born, pretty much, because if we don't find those problems, then they're not going to be able to develop as well and learn in school properly and all this kind of thing. The same is true for eczema if a kid's skin's on fire and itchy and not sleeping and scratching at school and all that kind of stuff. It's not just a skin issue, it's affecting a critical part of their development. So, yes, I agree that we probably are situating change if we start early on, but I also think even if we weren't, it would still be worthwhile to get aggressive early on because of these other reasons with development. And I always get asked, you know, as someone who whose first love was pediatrics, you know, how how early do you start a kit? Or when do you have that discussion about a shot, you know, biologic treatment like depixant with a parent? And I say as soon or earlier than my adult patients I see, because they're having their whole development be affected by this disease and probably affecting the whole family as well. And things like the proper amount of sleep at night and being able to be alert and pay attention during school and things like that, those are like critical for a child's development.

SPEAKER_01 42:54

Yes. And I know a lot of people are throwing around the the term like cumulative life course impairment, that a lot of the conditions we see and treat as dermatologists, the there's additive downstream issues that occur as a result, and those things occur and pile up over time. And I think eczema is one of the leading causes of cumulative life course impairment in my practice.

SPEAKER_02 43:21

They they've looked at quality of life measures, and you wouldn't believe, I mean, like skin disease that's itchy, like eczema and and chronic hives and paragonodularis, those rate way higher on like the impact on people's lives than some diseases that you would think of, or way, you know, like if you said asthma or eczema, you say, well, asthma, I can't breathe, you know, and eczema is a skin rash. Their eczema is way more impactful their life. It's on the order of like someone who has type one diabetes who has to like do insulin four times. That's how impactful it actually is on their life. So sometimes I think, especially, especially providers in other specialties, maybe kind of discount skin disease. Is, you know, it's a rash, but to patients, it's actually really impactful on their quality of life.

SPEAKER_01 44:05

Well, and that segues nicely to the last thing I wanted to get your opinion on before we do a fun rapid fire speed round. I find that sometimes in clinic, I'm trying to convince families that it's a good idea to treat and manage their child's atopic dermatitis, even though the burden is so great. I find that there's a lot of fear sometimes. There's more fear of the treatments than there is of the condition. And, you know, I don't think there's a parent out there that would decline treatment for their child's asthma. Because of course it's scary when your child can't breathe effectively. But I feel like almost every day I'm seeing a family where I'm really pushing them to do something. What are your thoughts and feelings on that?

SPEAKER_02 44:52

I think a lot of it came down to a scary word called steroids. And you say, I want to, I want you to give your kids steroids to make this go away. It's like, well, he has a rash, or I could give him the scary word steroid. So the good news is today we don't have to use any steroids for eczema patients. So we have great topicals that are non-steroidal, we have great systemic treatments that are non-steroidal that are very targeted. So I think that's part of it. And I think the other part is some people are really kind of all in on the natural types of treatments. And that's where I think you have to work together and say, hey, I'm not discounting natural things. There's great, there's great treatments that derive from natural products, and there's there's terrible things that are natural, you know, like cyanide is natural. Oh, so is digoxin. It helps people's heartbeat normally. So those are both derived from natural sources. So it's not natural or not natural. It's not necessarily steroid or not steroid. It's how targeted and safe is this treatment and how effective is it? So I think debunking some of the steroid stuff and then not discounting people's natural feeling to want to do things that are, you know, naturally derived and not something that's made in a laboratory. And I think you can work with people to try to do both. One one thing that I do that I think is very effective in kids, if kids have a low zinc, if kids have a low zinc level when you check their zinc levels, it is like magic if you replace their zinc. So the wor the worst eczema patients have a disease called acrodermatitis entropathica, where their gut does not absorb zinc well. But then there's a subset of eczema kids that because of diet or gut or combination or whatever it is, they actually have low zinc levels. And you could like give them every cream and every everything under the sun. But if you don't replace their zinc level, it's not going to get better. And if you do replace it, they will get better. So I'm an advocate for doing multiple different approaches at the same time. But if you can get them off the word steroid, that helps a lot.

SPEAKER_01 46:54

Yeah. You know, you taught me that about the zinc. And I'll be honest, I've been a poor adapter of it simply because I feel a little bit bad ordering a blood test uh in a in a young patient if that's the only thing we're checking. Do you ever just have them like try zinc supplementation instead of checking the lab? Do you ever just have them try it?

SPEAKER_02 47:12

Yeah, you can. You can just start with like a relatively modest dose of zinc and see them back in a month or two months. I would just say, especially if you're kind of uh gonna be a new adopter to it, don't give them a ton of other stuff because you're gonna think the other stuff did it or whatever. Like, you know, a little cream here and there is fine, but especially if they're if they're hesitant to do other treatments anyway, and you say, okay, well, I heard this one guy on a podcast and he said uh you should try this. Zinc's a natural substance that everyone needs to absorb anyway. It's a it's basically a vitamin. So let's try this. We'll just do a like a you know, lowish type dose, a normal dose, and then we'll see you back. And then I'd love to hear, I'd love to hear uh if you try it out, how how it went.

SPEAKER_01 47:52

Yeah, yeah. And I think what people would say is I heard this guy on this amazing, wonderful podcast called Skin Credible talking about that. I think that's what they would say. And he does magic on the side, and they were impressed by that. Okay, so so appreciate you taking the time to do this, Dr. Mark Sarota. I know that you are so, so busy. You do all this side hustle stuff. You've got the you do some obesity medicine, you have your allergy practice, your dermatology practice, your magic practice, you have all these things. And so I so appreciate you being with us. And I wanted to end by having a really fun, rapid fire speed round, kind of get to know you better, Mark Sarota. Are you ready?

SPEAKER_03 48:30

Okay, I'm ready.

SPEAKER_01 48:31

Okay, okay. So, number one, if you could have a superpower, what would it be? Would you want to be invisible? Would you want to be able to fly? Would it be teleportation? Would you be invincible?

SPEAKER_02 48:44

Wow, that's a great question. I feel like there's so many like there's so many like unintended consequences you could you can get from that. Um okay, I'll I'll say I would love to fly because I love to travel, but I hate the actual travel. So if I could fly really quickly, that would be amazing.

SPEAKER_01 49:00

Well, and to that point, I think I would choose teleportation because you could just be somewhere else. Just like boom.

SPEAKER_02 49:06

Okay, I agree. But I'd want uh you got to enjoy the journey, you know, you gotta enjoy the journey.

SPEAKER_01 49:10

I guess that's true. I guess that's true.

SPEAKER_02 49:11

You're gonna miss all the cool scenery if you just get there.

SPEAKER_01 49:14

Yeah, that's true, but I'm afraid of height. So I think I would still choose teleportation. Um, question number two. We're approaching Easter. Cadbury eggs or Reese's peanut butter eggs?

SPEAKER_02 49:24

Okay, so we talked about allergies and how like, you know, you can you can't pass down allergies to your kid. My parents did not know that, and they told me I was allergic to chocolate my whole life. So I do I love every food except chocolate. Like, I don't eat chocolate, and I'm like such a foodie. So my son thinks I'm a total weirdo that I don't eat chocolate. He tells like strangers, so he'll be like, we were in the supermarket. He's like, You got my he doesn't eat chocolate, just so you know, isn't that weird? So so I actually I like the um I like the peeps like um marshmallow things. Yeah, he'll do those. Oh yeah, those are awesome.

SPEAKER_01 49:55

And so do you think because you were forced to avoid it, you just never developed a taste for it?

SPEAKER_02 50:00

Yeah, people people get like a aversion to it. So we'll have parents that bring their kid in and they say, like, I want him tested for peanut. And I'm like, I know he's not alert, like he's not allergic to peanut. We have to do a great oral challenge, but he's totally not allergic. His testing is zero, like it's all fine. And the kid, the kid won't eat it. They won't, they physically won't eat it. So, you know, when we do a graded oral challenge, it's like, are they old enough to tell me if they're feeling a problem? And will they reliably eat the food when I tell them to eat the food? So, you know, there there was a kid we in my fellowship we did we had to do lobster testing, and the mom brought in these like lobster tails, and the kid refused to eat it. So we just have we just had lunch, we just had lobster tails in the in the allergy fellowship.

SPEAKER_01 50:40

I love it. I love it. You know, I think though, Mark, if if I was in your situation with the chocolate, I think I would power through. I think you're giving up too early. I think you need to keep trying it.

SPEAKER_02 50:50

I've tried, I've tried.

SPEAKER_01 50:52

You're like, I've been there.

SPEAKER_02 50:53

I uh it's like it's so bitter, it's like bitter to me. You could give me like, you know, like the reality shows they make them eat the gross foods or I would literally eat like worms or whatever else if you put like chocolate cake or like warm, I would eat whatever the other thing wants.

SPEAKER_01 51:06

Wow, crickets? They say crickets are high in protein. They say eventually we'll be eating crickets.

SPEAKER_02 51:11

Um I'm in favor of it. I think it's fine.

SPEAKER_01 51:13

Are you? You're pro-cricket? Okay. Or I guess if you're eating them, you're anti-cricket. Okay. Question number three: going out to dinner versus cooking at home.

SPEAKER_02 51:21

Going out. That's so I'm going out to dinner for sure. Yeah. That's me too. That's easy.

SPEAKER_01 51:26

Me too. Your favorite dinner out, what kind of restaurant do you choose? Do you do steakhouse, Italian, Chinese, Thai, sushi?

SPEAKER_02 51:34

I could eat like sushi every night of the year. Um, and we have a great sushi restaurant in Denver called Sushi Den. And literally the two chefs that own it are like master sushi chefs. They just got a Michelin star actually for their like little tiny sub-restaurant. But the third the third brother lives in Tokyo, and every other day he goes to the Tokyo fish market and sends over like whatever the good stuff is. So they have like a refrigerator of like hanging humongous tuna things and whatever. So I'm out, I'm doing I'm doing a talk there, and I was like, guys, you think people are gonna come from downtown, like drive 20 minutes to like this Wash Park area for this? And they were like, Not for your talk, Mark, but it's sushi den. So like it's already filled up with like just provided. I was like, oh, okay. So yes, if anyone's in Denver, Sushi Den.

SPEAKER_01 52:18

No, 100%. I echo this. I lived in Denver for 10 years. Sushi Den and Izakaya Den, its sister restaurant. They're like right next door to each other. They are both phenomenal and amazing. And yeah, I mean, can't say, can't say more good about those places. They're so good. Number four, Coke versus Pepsi.

SPEAKER_02 52:36

I'm not a big soda drinker, but when I drink soda, it's you know, once you do the obesity medicine boards, you realize like sugary drinks are basically like the cause of all your problems. Um but if you're but when I when I do have the occasional soda, root beer or like a root beer float is like amazing. So beer float. Yeah, you gotta like you gotta mix it so it's like more of like a shake with like you know, you don't want like just a big blob of ice cream, you want like blended together. But yeah, root beer float, root beer for sure.

SPEAKER_01 53:02

That's where it's at. My brother always liked root beer floats. Number five, and there's uh there's there's five. This is the last one. Road trip versus cruise.

SPEAKER_02 53:10

God, I did a cruise, but the cruise was like on carnival, and it was when I had like I had no resources and I didn't know what I was doing, and I was trying to just have like a really inexpensive vacation. So it was like it was like all college kids, and like there was like lines for the buffet. I could just like I guess I guess I'll say I'll say road trip, road chip.

SPEAKER_01 53:31

So you were, I mean, your cruise experience sounds like mine. I had a similar trip, like spring break in college with my friends. We were in steerage, we were like, we were in one of those root like windowless rooms. I don't even know they if they allow that anymore, but we were in one of those windowless rooms. It was awful. It was not good. Yeah, yeah.

SPEAKER_02 53:50

There's probably some really nice cruises out there. I have not taken one, so I'm gonna say road trip. But if anyone has good experience with a cruise somewhere, let me know because I'm I'm down for something a little bit better.

SPEAKER_01 54:00

I think I would do like an Alaska cruise or like a Viking river cruise in Europe. I think I would do one of those.

SPEAKER_02 54:06

My issue is like I feel like if you do cruises, you can never really like get to know an individual place because you're just like there for a few hours or a day and then you're like back on the boat a lot. So I guess if you want to see a lot of places quickly, it's good, but then like the idea should be like find the places you thought were cool and you like, and then like do like a real trip there because you're just getting like a like an overview.

SPEAKER_01 54:27

An overview, yeah.

SPEAKER_02 54:28

They should do they should do like Dr. Durham meetings and stuff. They never do on cruises. That'll probably be good.

SPEAKER_01 54:33

I know that would be so good. Maybe we could even do like a podcast cruise and we could record live episodes of the podcast and have guests on talking about the stuff and have a live audience.

SPEAKER_02 54:44

Yeah, they should do like below deck Mediterranean clinical or whatever, you know. Like I would totally do that.

SPEAKER_01 54:50

Below deck MD Mediterranean. Well, thank you so much, Mark Sorota. This has been magical.

SPEAKER_03 54:58

That's all you did there.

SPEAKER_01 55:01

Um, thank you everybody for listening. Keep listening. We're gonna have a lot of awesome episodes on Skin Credible where you can keep learning incredible information about your skin.