Healing Psoriasis From The Inside Out with Dr. Todd LePine - Transcript

Dr. Todd Lepine (00:00): One of the key things I always ask my patients also is the component of stress. Not that stress causes psoriasis or stress causes autoimmunity, but stress affects the immune system. Dr. Mark Hyman(00:15): Welcome to this special episode of the Doctor's Farmacy that I call, House Call. And I'm sitting down with my colleague at the Ultra Wellness Center in Lenox, Massachusetts to discuss some difficult medical conditions that have amazing solutions using functional medicine that you won't get by going to your regular doctor. We're getting to the root cause of things. And today I'm sitting down with Dr. Todd Lepine who's been one of our featured guests on the Doctor's Farmacy talking about all sorts of conditions and has the second most popular podcast on the Doctor's Farmacy, I would say. Congratulations on that- Dr. Todd Lepine (00:45): Thank you. Dr. Mark Hyman(00:45): Which is no small feat. We've been working together for 25 years, maybe? Dr. Todd Lepine (00:52): Long time. Dr. Mark Hyman(00:55): 20 something like that. At Canyon Ranch for 10 years and then here at the UltraWellness Center for over a decade. Dr. Lepine went to Dartmouth Medical School, he's board certified in internal medicine and he's certified in functional medicine, integrated medicine and he's one of the smartest guys out there when it comes to understanding the body and how to heal it. I've learned so much from Todd over the years as my colleague and friend and we are privileged to take care of some really challenging cases at the UltraWellness Center. And today we're going to talk about psoriasis. Dr. Mark Hyman(01:20): Welcome, Todd. Dr. Todd Lepine (01:22): Thank you. Thank you, Mark. Dr. Mark Hyman(01:22): Now, this podcast is about things that matter and if you have psoriasis, probably nothing matters more than figuring out how to fix it because it's what they call, the heartbreak of psoriasis. And the reason is it's a miserable condition where you get thick, scaly, plaques, and irritation on your skin, which itches like crazy and it's scarring and disfiguring and it's just a miserable disease. And traditional medicine doesn't really have a lot of great treatments, except ones that are extremely expensive and often come with very significant side effects. Dr. Todd Lepine (01:56): Yeah, exactly. Dr. Mark Hyman(01:57): Todd, what's the general view of psoriasis in traditional medicine? Dr. Todd Lepine (02:02): The general view is that it's an external condition. Dr. Mark Hyman(02:05): It's a skin problem. Dr. Todd Lepine (02:06): It's a skin problem. Exactly. It's a skin problem and it's a chronic condition and there's no cure for it. That's the take home that you get in my training. And it really is not a skin condition. It's a systemic condition. And the ways in which we're treating it is really, as you said, very expensive and potentially very toxic. There are lots of things and I think this is probably almost like the paradigm condition from a functional medicine approach is where you get so much leverage because there's not one thing that causes psoriasis. There's not just one case of psoriasis. There's many variables. We were talking about that earlier, how there's a genetic component to it. There's the dietary component. There's the environmental component. Vitamin D, I'm a big proponent for vitamin D and I have so many patients who have psoriasis, who tell me that they get better in the summer when they go to the beach and they're in the salt water and they get sunshine. Dr. Mark Hyman(03:06): Well, that's one of the medical treatments is UV light, right? Dr. Todd Lepine (03:08): Absolutely, yes. Dr. Mark Hyman(03:09): They do stick people under lights and do light therapy in medicine, believe it or not. Dr. Todd Lepine (03:12): I think they also, it's an older therapy they used to use also, was is it? [inaudible 00:03:19] would inject it into you. It's like an older way, but nonetheless, UV light is very, very beneficial for modulating the immune system. One thing that really, I'll never forget this case and you probably have seen it yourself, but when I was in my regular conventional practice, I had a patient who presented with guttate psoriasis. Dr. Mark Hyman(03:40): Guttate psoriasis? Dr. Todd Lepine (03:41): Guttate psoriasis. And for those who don't know what guttate psoriasis is, it's what happens after- Dr. Mark Hyman(03:46): It gives you a gut ache. Dr. Todd Lepine (03:48): That's actually [crosstalk 00:03:49] that's a good way- Dr. Mark Hyman(03:49): It's actually guttate with a T, but it sounds like gut ache, but it could be that. Dr. Todd Lepine (03:52): Exactly, that's it. Dr. Mark Hyman(03:52): Actually, it may be that. It may be caused by the gut. Dr. Todd Lepine (03:54): Exactly. Dr. Mark Hyman(03:54): We'll get to that. Dr. Todd Lepine (03:55): That's a good point. It's G-U-T-T-A-T-E, guttate psoriasis and a patient who I had treated for a strep throat infection and then like a week or two later, she comes back and she's covered in these a dime to quarter sized circular, psoriatic lesions. And I'm like, what's going on here? I did a little bit of research and I found out that that is a well-known condition of post streptococcal guttate psoriasis. And I treated her with an antibiotic and guess what? Her guttate psoriasis went away. Dr. Mark Hyman(04:28): Amazing because you treated the strep, the cause. Dr. Todd Lepine (04:31): Exactly, exactly. The one thing that you need to realize is that strep bacteria is oftentimes involved in cross-reactivity. That's why people are so onto strep throat because if you get a strep throat in certain individuals, genetically susceptible individuals, they can get glomerulonephritis, it damages your kidneys. Dr. Mark Hyman(04:49): Kidney, right. Dr. Todd Lepine (04:50): You can get rheumatic heart disease, you can get PANDAS syndrome- Dr. Mark Hyman(04:55): Which is what? Dr. Todd Lepine (04:55): Pediatric Autoimmune Neuro Developmental Strep infection. You get this like OCD and behavioral type conditions and you can also- Dr. Mark Hyman(05:04): You get psychiatric issues, cardiac issues, kidney issues- Dr. Todd Lepine (05:06): Everything. Exactly. Dr. Mark Hyman(05:08): And they can be deadly. Dr. Todd Lepine (05:09): Absolutely. So strep bacteria play, I think, probably are one of the key players in some cases of psoriasis in patients. Absolutely. Dr. Mark Hyman(05:19): Well that is fascinating. Essentially, this is seen as a skin condition that's inflammatory and the treatments are using powerful anti-inflammatory drugs, including steroids- Dr. Todd Lepine (05:30): Absolutely. Dr. Mark Hyman(05:30): And a lot of them are topical steroids. [inaudible 00:05:32] it's topical, but they use very strong ones that get absorbed- Dr. Todd Lepine (05:35): Oh, absolutely. Dr. Mark Hyman(05:35): And they really suppress your own adrenal glands and have long-term consequences. Dr. Todd Lepine (05:41): And in the skin, because they're very, very power, they're not like the over-the-counter hydrocortisone. These are really high potency fluorinated steroids and they get absorbed into the system. They do decrease inflammation, but they thin the skin and you get breakage of the skin and such. Even though they're creams, there's systemic side effects to them. Absolutely. Dr. Mark Hyman(06:00): I also see that the drugs that are being used now and that are promoted on television are these very expensive, we call them, immunosuppressants. They're called TNF alpha blockers or biologics that- Dr. Todd Lepine (06:13): Yeah, Stelara and- Dr. Mark Hyman(06:13): Are maybe $50,000 a year. And they can be effective and help people for sure, but they do lead to immune suppression, especially in this time of COVID, if you're on one of these drugs, you're much more likely to have your immune system not work when you get an infection. Dr. Todd Lepine (06:30): Exactly. And there are times when, there are some patients, I have seen some patients with either rheumatoid arthritis or significant psoriatic arthritis, which is psoriasis to the next degree where you're developing systemic symptoms of joint inflammation. Sometimes you do have to use the biologics to more or less put out the fire for a period of time. Absolutely. It's not as though I'm against biologics, there's a time and a place for everything- Dr. Mark Hyman(06:53): For sure. Dr. Todd Lepine (06:54): But those are sort of the last ditch. That's like, okay, break the glass, pull out the emergency fire extinguisher and put out the fire. Dr. Mark Hyman(07:00): It reminds me of this case, I'm going to share for a minute, which is a little girl came to see me. She was probably like four at the time. And this is really how we think differently in functional medicine because in functional medicine, we see this, like you said, it's a systemic problem that happens to affect the skin. And if you're treating skin, it's just putting topical stuff on that doesn't really have systemic effects or get to the root cause. Functional medicine is always about the root cause. Dr. Mark Hyman(07:24): And this little girl, when I looked at her history, born by C-section, not breastfed. Already, she's got a reduction in her healthy microbiome formation because going through the vaginal canal populates the gut with bacteria that are healthy. Breastfeeding provides these oligosaccharides that are essentially non-digestible food for the good bacteria. And so the kid's already set up for problems. Then got ear infections, antibiotics, just layered on, and then developed this horrible psoriasis at a very young age, like a year old. Skin was just covered with it. And the kid was on and off steroids, antibiotics for skin infections because often if the psoriasis is bad, it'll break down the skin, the skin will get infected and you get in this vicious cycle. And this girl ended up on one of these drugs, these biologics, that suppress your immune system because she had it all over her body. And she ended up in the intensive care unit with sepsis for a month. Dr. Todd Lepine (08:16): Wow. Dr. Mark Hyman(08:16): And the reason she got sepsis or overwhelming systemic infection was because her immune system was suppressed on the drug and it was suspicious cycle. The parents came to me, were desperate and this little girl was so sweet. She had really head to toe psoriasis. It was not the normal kind. And she went to the bathroom in my office and she was screaming when she went to go pee because the peeing hurt because she had it all over her vagina. This kid was just a mess. Dr. Todd Lepine (08:40): Mess. Dr. Mark Hyman(08:41): And I'm like, well, let's start with the basics, diet and also helping her gut get sorted out. And I think for most people with inflammation in their body or an autoimmune disease, the main thing we look at is the gut. And for this little girl, I started with an elimination diet, gluten, dairy. And gluten, of I look at psoriasis, probably one of the biggest factors. Dr. Todd Lepine (09:06): Yep, absolutely. Dr. Mark Hyman(09:07): I got rid of the gluten, got rid of the dairy, cleaned up her diet, got rid of the sugar and stuff. And because of all the antibiotics and steroids, the immune [inaudible 00:09:15], I gave her in any fungal, just on an assumption because there's a lot of evidence that yeast plays a role or fungal infections play a role. That's why they use sort of antifungal shampoos for scalp psoriasis or dandruff. And I put her on this program. I got a call from the father a couple of weeks later and how's she doing? And he said, "She's almost completely clear." Her skin completely cleared within like a few weeks. And then she did really, really well for a long time. And then her scalp just never recovered. And I said, "What is she eating?" "Well, she's having gluten-free oats." And I'm like, mm-mm (negative). I think, oats, even though they say gluten-free are often cross-contaminated or not perfectly gluten-free. And so I got her off of that and her scalp cleared and the kid's fine. Dr. Mark Hyman(10:01): And so this is a case where you do something really simple and when you get an incredible result by fixing the root cause. And when I did her testing, she did, she had terrible gut microbiome on the stool testing. She had elevated antibodies to gluten. We use not just a regular celiac or anybody who has, we look at 20 different proteins that are in wheat and gluten. And we look at antibodies against them and she just lit up like a Christmas tree. I was like, wow, this is the worst I've ever seen. Dr. Todd Lepine (10:30): Wow. Dr. Mark Hyman(10:30): And yet, she got better so fast by dealing with the right cause. Dr. Todd Lepine (10:37): And that's the kind of case that really sticks in your head. And the one thing about psoriasis, I think also, people who have it, it's one thing if you have like a couple of lesions on your elbows and they're hidden. It's not a big deal, but if people have really bad psoriasis, it's pretty much like having leprosy. You pretty much don't want to expose your skin. You don't want to go out bathing and such- Dr. Mark Hyman(10:58): It's embarrassing. Dr. Todd Lepine (10:59): It's embarrassing, right, and people think it's contagious. It's all these sort of myths about it. And it definitely has, I think, a psychological toll for people who have really significant psoriasis. Absolutely. There definitely is that psychological component to it. And you see these advertisements where, I think, shows people by the pool taking their biologics so that they can now go bathing, but you got to take this expensive, expensive, toxic medications just to jump in the pool. Dr. Mark Hyman(11:26): You and I are old enough to remember a time when there was no advertising for drugs on television. Dr. Todd Lepine (11:31): Absolutely. Dr. Mark Hyman(11:32): And what these advertisement do is they work and the studies have shown that 40% of the time when the patient goes to the doctor and says, "Hey doc, I saw this ad for blabity blah on TV. Can I get that drug?" They're like, "Sure." These are working and that's why they spend billions and billions of dollars on these ads. And it's wrong because in functional medicine, there is an incredible pathway to help these patients. Do you have any other cases that come to mind? Dr. Todd Lepine (11:59): Yeah, absolutely. I just had a recent a case where, and this was like a very interesting case because the patient had a little bit of a perfect storm for getting set up for psoriasis. The patient developed a lot of strep throat infections in her twenties. All of a sudden she's developed lots of strep for whatever reason, maybe contamination from her kids or whatever, and then was put on a variety of different antibiotics. And then after the birth of one of her children, she had a [inaudible 00:12:32] cystectomy because she developed gallstones. Dr. Mark Hyman(12:34): Gallbladder out. Dr. Todd Lepine (12:35): Gallbladder out, exactly. Gallbladder out. And there's actually some really interesting evidence about the role of the bile acids in psoriasis. It's really quite interesting and that's what sort of triggered it. And then to sort of add fuel to the fire, the patient was on, guess what? A PPI- Dr. Mark Hyman(12:54): Acid blocking [crosstalk 00:12:55]- Dr. Todd Lepine (12:54): Proton pump inhibitor, the purple pill. Exactly. We're going to talk about that in the next podcast. This patient was a little bit of a setup for a perfect storm for developing psoriasis. Then also had some stress in their life. And then also one of the other things that you see in psoriasis in some patients is metabolic syndrome. If you're overweight, if you have pre-diabetes, that's another potential risk factor for developing psoriasis. And then originally the patient, if I recall, had a vitamin D level originally that was in the single digits. Dr. Mark Hyman(13:31): It should be like 40 or 50 and you're saying it was like [crosstalk 00:13:34]- Dr. Todd Lepine (13:34): Less than 10, less than 10. Dr. Mark Hyman(13:35): Which is very, very, very low. Dr. Todd Lepine (13:37): I get on my soap box here because this is one of my things that I just love to talk about this is that a low vitamin D level is not the problem. It's a symptom of the problem. Dr. Mark Hyman(13:49): Okay, tell us what you mean. Dr. Todd Lepine (13:51): Vitamin D is a biomarker for sunshine exposure. We talked earlier about the use of sunshine and ultraviolet light, which you get through sunlight exposure. Yes, sunlight can cause skin cancer. It's associated with photo aging and wrinkles and all that kind of things. Excess amount of sunlight and sunburn is not healthy for you, but healthy sun exposure is really, really beneficial. Dr. Mark Hyman(14:15): Cover your face and put a hat on, put sunblock on your face, but the rest of your body- Dr. Todd Lepine (14:20): Get exposed to healthy sunshine. Absolutely. And then in the winter, I personally will take vitamin D during the fall and the winter because you're not going to get it. If you live north of the Mason-Dixon line, you're not going to get the healthy sunshine, but- Dr. Mark Hyman(14:32): I'll push back on that, Todd, because I see patients in the summer who think, oh, I'm not taking my vitamin in the summer and they think it's fine and you're just out walking, but you need to have full body exposure for 20 minutes, between 10:00 and 2:00 and if you live below Atlanta, it's tough to get. And I think it's only the summer, but people aren't getting that exposure, so they're often low in the summer. Dr. Todd Lepine (14:54): And the other clinical pearl to this, Mark, and I learned this from another doctor, she practiced down in Mexico, and she used to see a lot of people in Mexico with low vitamin D and you figure, oh, they got plenty of sun down there. Well, lo and behold on, on your skin is sebum, which is a waxy substance. And that sebum material is a cholesterol derivative. And you have to have healthy oil on your skin to get photo activated by the ultraviolet light. So guess what, what do most people do every day? Dr. Mark Hyman(15:24): Shower. Dr. Todd Lepine (15:25): They bathe in hot soap and water all the time. And it's one thing if you're outside, you're digging in the dirt and you really get dirty, but most people don't need to be bathing in hot soap and water every day. You can bathe with soap and water to the private parts and your armpits, but we over bathe. Guess what we do, we wash off that healthy oil on the skin, which prevents the synthesis of vitamin D. That's a clinical pearl. Dr. Mark Hyman(15:48): That's good because see, I only use soap and water on those private parts, as you say, and the rest I just water- Dr. Todd Lepine (15:54): Exactly. Dr. Mark Hyman(15:54): And I don't actually wash my body with soap. Dr. Todd Lepine (15:56): Exactly. Dr. Mark Hyman(15:58): And I think it- Dr. Todd Lepine (15:58): There are some people that [crosstalk 00:16:00]- Dr. Mark Hyman(16:00): Probably shouldn't announce that, but- Dr. Todd Lepine (16:01): They'll bathe like twice a day. Dr. Mark Hyman(16:02): I think I smell okay. I don't know. How am I doing, Todd? Dr. Todd Lepine (16:04): Yeah. Exactly. Vitamin D, again, is a biomarker for sunshine exposure. And there's a great video, which I oftentimes will have my patients watch. It's on YouTube. I would highly recommend everybody go to it. It's a two minute video. It's called the indoor generation. I don't know if you've seen it. It's fantastic. And it talks about how we as human beings spend most of our time closed and indoors. It actually has an effect on the immune system, it has effect on our immune system indirectly because of lack of sunshine and vitamin D. And it's a great visual about trying to get ourselves outside in fresh air and sunshine. Dr. Mark Hyman(16:50): Hey everybody, it's Dr. Hyman. Thanks for tuning into the Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you to all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's picks. It's my weekly newsletter and in it, I share my favorite stuff from foods to supplements to gadgets to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else I promise. And all you have to do is go to dhyman.com/picks to sign up. That's drhyman.com/picks P-I-C-K-S and sign up for the newsletter. And I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer. Now, back to this week's episode. Dr. Mark Hyman(17:45): Just listening to your talk and the with problem traditional medicine is we don't have a methodology to navigate to the cause of the problem. And we have the ability to diagnose something based on what it looks like, where it is in the body and the pathology. And that's what we follow. Psoriasis is a diagnosis that tells you the name of what's wrong with you, but doesn't tell you the cause. Dr. Todd Lepine (18:11): Exactly. Dr. Mark Hyman(18:11): And so you can have psoriasis, but it could be four or five different things like gluten, yeast, a microbiome issue, the strep, heavy metals, all kinds of issues that people aren't, vitamin D issues- Dr. Todd Lepine (18:25): Genetics. Dr. Mark Hyman(18:25): Genetics, right. We have to really navigate for that particular person what the cause is and it's different for different people. I just show one more case. Then I want to talk about how we work up the cases. This was a patient that came to see me who had psoriatic arthritis, which is- Dr. Todd Lepine (18:40): The patient I was talking about, same thing. Dr. Mark Hyman(18:41): Which means that joints get destroyed. It's not just the skin, but it's starting to affect the joints. It's an autoimmune issue. And these drugs are expensive. And she had all these other issues that she complained about. So she goes to the dermatologist and he was like, okay, I'm going to treat your psoriasis and psoriatic arthritis. And the rheumatologist gives her the rheumatology drugs, but she also had terrible bloating and irritable bowel and reflux. And she was on acid blockers. And she was struggling with bloating after eating and bacterial overgrowth. And she had depression and she had pre-diabetes and she was overweight and she was inflamed everywhere. And she was depressed and she couldn't sleep. And it was like, she was a mess. And I'm like, okay, well, what's going on? Well, one of her most bothersome symptoms was this terrible bloating after eating, which we call SIBO or bacterial overgrowth. We've talked about it on the podcast, essentially the bugs grow in the small intestine, you eat food and then they ferment and blows up and you feel like you have a food baby. Dr. Mark Hyman(19:35): Well, I treated her with an antibiotic to clear out the bad bugs. I gave her an antifungal to clear out the yeast and I rebuilt her gut using what we call the 5-R program in functional medicine, which is a gut restoration program. And I gave her basic multivitamin, vitamin D and fish oil, not a whole lot of stuff, probiotics, get her gut healthy. And she comes back six weeks later and she's lost 25 pounds. Her depression is gone. She's sleeping. She's got no more bacterial overgrowth, no more reflux, no more heartburn. She's off her drugs. I didn't tell her to stop the biologic she was on for arthritis. She stopped it. Her psoriasis was gone, her arthritis was gone, her bacterial overgrowth's gone. Everything was gone in six weeks. And I'm like, it may sound like a miracle, but it's not a miracle. It's just using the right strategy and the right map to figure out what's wrong with the person. And we do this over and over in functional medicine. If you're out there suffering from the heartbreak of psoriasis or eczema or acne, all these skin conditions, they're systemic conditions that we have to think about the cause. Dr. Mark Hyman(20:34): Todd, tell us, how do we figure out in functional medicine what the root cause is? What are the tests that we do? How do we look at patients differently? And let's get into what we do to treat them. Dr. Todd Lepine (20:42): Some of the testing that I like to use is looking at gluten sensitivity, as you mentioned before. We'll do the testing where we check for the antibodies against gluten and the breakdown products of gluten. Gluten is this big, long protein and proteins are made up of amino acids and they have to get chopped up. And the test that we do, which is the Cyrex testing, it looks at a whole bunch of different protein fragments of the gluten protein and that shows antibodies to this. That's, I think a very, very valuable test. The one caveat is that if patients are on immunosuppressant medications or steroids, you may get a false negative test. Dr. Mark Hyman(21:21): Or if they've been taking immunoglobulins, which is for different disease treatments, they can get false positives. Dr. Todd Lepine (21:28): That's true. That test is very helpful. And then testing for intestinal permeability, the test that I- Dr. Mark Hyman(21:34): Leaky gut. Dr. Todd Lepine (21:35): Leaky gut. Leaky gut. My explanation to patients, patients say, "Well, what is leaky gut?" Very, very, very simple. Just imagine you have a screen door in your house and the screen door lets the air in, but it keeps the mosquitoes out and when you have a leaky gut, your screen door has holes in it and the mosquitoes are coming in. That's essentially leaky gut. That's the best way to understand it. It's more complicated than that, but- Dr. Mark Hyman(21:57): That's good. I use a coffee filter. I'm like, you've got coffee filter lets in the coffee, but not the grinds, but it's the same idea. Dr. Todd Lepine (22:02): Same idea, same idea. And so the leaky gut test is really good because what it does is it checks for the antibodies to Zonulin. So Zonulin is this molecule. Alessio Fasano did a whole bunch of research, fantastic- Dr. Mark Hyman(22:13): He's a Harvard expert on celiac. Dr. Todd Lepine (22:14): Yeah. Harvard expert on celiac and the connection between celiac and all different kinds of autoimmune conditions. When your body has leaky gut, it produces Zonulin and over time, Zonulin can cause antibody formation to the Zonulin. So when you have antibodies to Zonulin, it tells you that over time, you've had long [crosstalk 00:22:35]- Dr. Mark Hyman(22:35): You've got a leaky gut. Dr. Todd Lepine (22:35): Leaky gut, exactly. You can have transient leaky gut, like every time anybody, even if you don't have celiac, anybody who eats gluten will have transient leaky gut. Your Zonulin levels will go up, but then they come down. But when you have antibodies to the Zonulin, that's when you really know this more of a chronic kind of infusion. And then the other- Dr. Mark Hyman(22:54): And you don't have to have celiac, by the way. Dr. Todd Lepine (22:56): Exactly. Dr. Mark Hyman(22:56): You could just have gluten sensitivity and this whole phenomenon of non-celiac gluten sensitivity is very real. It Affects millions and millions of people- Dr. Todd Lepine (23:04): Absolutely. Dr. Mark Hyman(23:04): And it's linked to all sorts of conditions, including a lot of autoimmune diseases. Dr. Todd Lepine (23:07): And it's a spectrum illness because I've had patients who had no symptoms throughout their life and all of a sudden they develop full blown celiac disease. You've seen that I'm sure. Dr. Mark Hyman(23:17): Yeah, of course, many times. Dr. Todd Lepine (23:18): And that's probably related to yes, there's a genetic component. Yes, there's an exposure component. It's probably also related to the microbiome because the microbiome is also tied in with celiac, too. Dr. Mark Hyman(23:29): That's right. Dr. Todd Lepine (23:30): It's really interesting. And then the other part of the leaky gut test, which I really like, is checking for antibodies against the LPS or lipopolysaccharides. These are the coatings of the gram negative bacteria in the gut- Dr. Mark Hyman(23:41): These are like bacterial toxins. Dr. Todd Lepine (23:43): Exactly. Dr. Mark Hyman(23:43): And they get absorbed. Dr. Todd Lepine (23:44): Endotoxins, exactly. Dr. Mark Hyman(23:46): And then your immune system reacts. Dr. Todd Lepine (23:47): And your immune system does not like these things. When it sees the gram negative endotoxins, it says, "Okay, full steam ahead. We're going to like really try to counteract this." And that's where you get this real systemic inflammation. When you talk about sepsis, when you get sepsis, you're getting bacterial endotoxins in your bloodstream and then you get a full cytokine storm. Yeah, exactly. Dr. Mark Hyman(24:13): It's incredible. We'll look at antibodies against gluten, against things that relate to leaky gut, look at cross reactions to other proteins that are in your food, whether it's dairy or other grains, which are really common. What happens is the gluten often opens the door, literally the leaky gut, and then all these other food proteins leak in and your body starts to react to those. So you get in this vicious cycle. Dr. Todd Lepine (24:37): Exactly, yeah. Dr. Mark Hyman(24:38): And getting rid of the gluten and healing the gut can usually help reverse a lot of that, but it's a big issue. And we also look at stool testing. Dr. Todd Lepine (24:44): Absolutely. Dr. Mark Hyman(24:45): Why are we looking at poop for the skin? Dr. Todd Lepine (24:47): Exactly. That's a good point. The microbiome and it's interesting because what is a healthy microbiome marker? What is what we call an eubiosis? It varies. It's a very interesting concept. And what do we call dysbiosis? What is an unhealthy microbiome? Dr. Mark Hyman(25:06): I often want to write a book called, Paleo Poop- Dr. Todd Lepine (25:08): Paleo, right. Dr. Mark Hyman(25:10): What is the indigenous microbiome? Dr. Todd Lepine (25:13): Exactly. Dr. Mark Hyman(25:14): What is it that we actually had as we were evolving- Dr. Todd Lepine (25:16): Exactly, exactly. Dr. Mark Hyman(25:17): To keep us healthy. Dr. Todd Lepine (25:17): Exactly. Yeah, absolutely. Dr. Mark Hyman(25:18): Because there's no autoimmune diseases. There is no psoriasis in hunter gatherers. There's no autoimmune disease. Dr. Todd Lepine (25:23): Interesting. Exactly. Dr. Mark Hyman(25:24): There's no allergies. Dr. Todd Lepine (25:27): To some degree, just like there's a museum, not a museum, but it's a research institute, that actually has in cold storage, all the seeds of the world. And I think that we actually need to freeze good poop because- Dr. Mark Hyman(25:40): I agree. I 100% agree. Dr. Todd Lepine (25:40): Because we may be running out of good poop. Dr. Mark Hyman(25:42): I'm like, we need to go to the Amazon and find that paleo poop. Dr. Todd Lepine (25:45): Exactly. Dr. Mark Hyman(25:46): The Hadza in Africa, we need to go. Dr. Todd Lepine (25:48): Exactly. Dr. Mark Hyman(25:48): Yeah, it's true because we really don't know even what the total healthy microbiome looks like. And it can change very quickly, depending on your diet. Dr. Todd Lepine (25:54): Absolutely. Dr. Mark Hyman(25:54): If you become a vegan, it looks one way. If you go paleo, it looks another way. It changes very quickly in response to your diet. Dr. Todd Lepine (25:59): Exactly. And the thing about it is that the microbiome is a dynamic. It's not a static process. It's always changing. And there are a variety of different companies out there that do testing. The test that I like and right now I think is probably the clinically most beneficial one is the GI map test because it does quantitative PCR. It's a great test. It's not a perfect test and there is no perfect test out there. Dr. Mark Hyman(26:25): [crosstalk 00:26:25]. Dr. Todd Lepine (26:25): There really isn't. There's a lot of controversy over like, well, what test? There's all different ones. There's Viome one- Dr. Mark Hyman(26:33): Genova, we use, the GI Effects. Dr. Todd Lepine (26:35): There's a whole bunch of them out there and they all have their role. But I think that the quantitative PCR, which is very, very sensitive and the key thing about that particular test is it's so sensitive. It'll pick up a bacterial DNA, which may or may not be significant. Oftentimes sometimes you'll see like- Dr. Mark Hyman(26:53): They have RNA, right? Dr. Todd Lepine (26:54): Yeah, RNA. And it will pick up bacterial DNA that, let's say you ate a hamburger and it was a little bit raw. You might have a little bit of [inaudible 00:27:03] hemorrhagic e-coli and it may come up on the stool test. Does that mean you have an infection from it? No. But I'd rather have a test showing me lots of data and then I can use my clinical judgment to say, "Okay, what's going on here?" And some people don't know how to really read the test, in my opinion, because they over read the test. You need to read it in the context. And I think that as time goes on, the stool tests are going to get better. We're going to have more clinical utility of them and again, we're just in the infancy stage of learning about the gut microbiome. Dr. Mark Hyman(27:37): We do food sensitivity testing, gluten testing, stool testing, look at vitamin D. Dr. Mark Hyman(27:43): The other thing I often think about is heavy metals. And there's a subset of patients who have autoimmune disease that have heavy metals because these compounds are toxic and they are immunotoxic at very low levels. It's not like you have to have a toxic load of this, but it may just trigger an immune response. Often I've helped patients looking at their heavy metal load. We do maybe challenge testing and other approaches. Now we've got the data, we're looking at their gut, we're looking at food, we're looking at vitamin D, we're looking at metals, maybe look at other factors, what do we do for these patients? How do we start to treat these patients? What is the functional medicine approach? Dr. Todd Lepine (28:15): Well, one of the key things I always ask my patients also is the component of stress. Not that stress causes psoriasis or stress causes autoimmunity, but stress affects the immune system. Dr. Mark Hyman(28:28): Affects everything else. Dr. Todd Lepine (28:29): Exactly, yeah. Exactly. I always get a handle on how much stress are you having your life? And also, how is your sleep? Those two things, if you're not getting good sleep and if you're under stress, that's like throwing gasoline on a fire. And you're not going to fix the issue until you address a good circadian rhythm and you also address a person's stress and lifestyle. Those are key things because that's not going to cure your autoimmune condition, but I can't tell you the number of times that I've had a patient who had an autoimmune condition that was triggered by a very stressful event, a divorce, loss of a job, loss of a child, you name it. Dr. Mark Hyman(29:07): Of course. Stress alone can cause leaky gut. Dr. Todd Lepine (29:09): Absolutely. Yes. Dr. Mark Hyman(29:10): Even in a healthy people. Dr. Todd Lepine (29:11): Exactly. Absolutely, yes. As you said, you address diet and the low-hanging fruit are things like gluten, dairy, sugar. Dr. Mark Hyman(29:21): What about grains? Do you put people on an autoimmune Paleo diet? Dr. Todd Lepine (29:25): Autoimmune Paleo diet for people who have significant autoimmune conditions, the AIP diet, I think, is probably the go-to diet. Dr. Mark Hyman(29:31): And what is that? Dr. Todd Lepine (29:32): That's where you eliminate gluten, sugar, grains, dairy, and- Dr. Mark Hyman(29:39): Beans. Dr. Todd Lepine (29:39): Beans, yeah like- Dr. Mark Hyman(29:40): Nuts. Dr. Todd Lepine (29:41): Well, and lectins. Lectins are another thing that potentially can play a role in some individuals causing leaky gut. Dr. Mark Hyman(29:47): And nuts and seeds and eggs even are taken out. If you're really an extreme situation, the idea isn't to be extremely restricted your whole life, but to remove all the things that are potentially a trigger for a short time, see what happens. If your skin clears up, then you can start adding things back- Dr. Todd Lepine (30:00): Exactly. Dr. Mark Hyman(30:00): Add the nuts, add the eggs, ass the nightshades, add all those things and see what happens. Dr. Todd Lepine (30:04): And the point of an elimination diet is not to eliminate all those foods for the rest of your life because a lot of patients will say, "Well, I can't do that." Well, I tell them, "Well, let's do it for like two months and let's see what happens." And it's sort of like cleaning the slate. It's basically decreasing the immunogenic load to the immune system via the gut. Most of your immune system is in the gut. When you're eating these foods, it can trigger the immune system. It can feed the bacteria. Not only are you eating the food, but the bacteria are eating the food. Dr. Mark Hyman(30:33): It's not just eliminating the foods, but it's also feeding the good microbiome with- Dr. Todd Lepine (30:37): Key thing. Dr. Mark Hyman(30:37): Lots of polyphenols and fibers. And good food. Dr. Todd Lepine (30:41): And we talked about that earlier about the Akkermansia and the Akkermansia shake, if you will, using polyphenols to increase that and it's a protective type of bacteria. Again, and then eventually you can then start adding in those foods. One food that I'll never add in, if somebody has a gluten sensitivity, I just like, that's it- Dr. Mark Hyman(30:58): That's it. Dr. Todd Lepine (30:59): I tell them, "It's kryptonite. Don't go near it." Dr. Mark Hyman(31:04): I like that. I like that. That's good. Dr. Todd Lepine (31:04): Don't go near it. Dr. Mark Hyman(31:05): We do that, but then not just eliminating food, but then we have to repair the gut and how do we do that? Dr. Todd Lepine (31:10): Well, you repair the gut, you can use food also. Ghee can be also very helpful, bone broth, which is high in collagen peptides. You can also use butyrate. Butyrate is probably one of my favorite go-to things nowadays. Our body produces butyrate. When we eat beneficial fibers, high fibers will actually get broken down and the body produces butyrate, but some people don't have those bugs that produce the butyrate. You can actually use butyrate in supplement form and actually some integrative doctors have used butyrate enemas for people with ulcerative colitis and ulcerative proctitis. Absolutely. Those are things and glutamine can be helpful. Aloe can be really beneficial- Dr. Mark Hyman(31:57): And probiotics and prebiotics. Dr. Todd Lepine (31:59): Probiotics. Exactly, yeah. Dr. Mark Hyman(32:01): And sometimes we also use medication to clear out all the bad guys. I call it the weeding, seeding and feeding program and in particularly in psoriasis, I think, people are cautious about anti-fungals, like Diflucan, but I've used this for 30 years. It's extremely safe drug. I really, knock wood, have had not one complication. People get some die off. One patient, I think, had with another doctor in our practice, had a liver issue and tried it and it made the liver issue worse. But if your liver is okay, it's really a pretty safe drug and it can be profoundly effective in a subset of patients. Dr. Todd Lepine (32:32): Are you talking about Diflucan? Dr. Mark Hyman(32:34): Yes. Dr. Todd Lepine (32:34): Yeah, Diflucan. The one thing with that is I think drug-drug interactions. If somebody is not on any drugs, they're much less likely to get complications. Like you said, if you have underlying liver disease, you got to be very cautious, but if you're not on any other medications and there's no underlying liver disease, it is quite safe. Dr. Mark Hyman(32:50): People are afraid of anti-fungals because when we were in training, you and I, back in the day, there weren't a lot of these newer antifungals. There was the old one called amphotericin, which we called amphoterrible- Dr. Todd Lepine (32:58): Terrible. Dr. Mark Hyman(32:59): Because it had terrible side effects, but now the new ones are not so bad. We also may have to go deeper than that even, maybe looking at heavy metals and detoxification. We really have a systematic way and believe it or not, if you really focus on your diet and clean up your gut, it often goes a long way and you can do this on your own without even seeing a doctor by following the instructions we gave or looking at some of my books, like the 10 Day Detox Diet, which provides that kind of anti-inflammatory diet. I'm really kind of excited that people can have hope for psoriasis- Dr. Todd Lepine (33:32): Yeah, absolutely. Dr. Mark Hyman(33:32): Because when I see someone's psoriasis, I get so excited because I'm like, slam dunk. This is what we got in functional medicine. And some things are harder. Like some things are harder to treat for sure. Dr. Todd Lepine (33:40): Absolutely. Dr. Mark Hyman(33:40): You have cancer or other problems, but this is one of those diseases in functional medicine that people should just not suffer from this. Dr. Todd Lepine (33:45): Absolutely, yeah. Dr. Mark Hyman(33:46): Acne, eczema, psoriasis, all these things are skin conditions that are starting as systemic problems that show up on the skin and you can't just lather [inaudible 00:33:54] on the skin and hope it's going to work. Dr. Todd Lepine (33:56): Exactly. And then also the whole aspect that psoriasis can lead into psoriatic arthritis, which really tells you, it's not a skin condition. You really shouldn't be seeing a dermatologist in my opinion, for psoriasis. Dr. Mark Hyman(34:08): [crosstalk 00:34:08] see an inflammologist. That's us. Dr. Todd Lepine (34:11): A psychoneuroimmunoendogutologist, like us. Dr. Mark Hyman(34:15): Well, Todd, this is great. For you listening out there, if you know anybody, if you've been suffering from psoriasis or skin conditions, have hope because using this way of thinking, functional medicine, we can really help these patients tremendously. Dr. Todd Lepine (34:28): Absolutely. Dr. Mark Hyman(34:28): We shared a bunch of cases. Some of them were pretty extreme and they do well. We at the UltraWellness Center here had been doing this for 15 years. Before that, we all were at the Canyon Ranch together for another 10 years before that. We have literally decades of decades of experience with these kinds of problems. And we'd love to see you. We're doing all virtual consults now. People don't have to travel here and they can do it over Zoom. And we can really help you with remote consultations and testing and working up what's going on and helping you. I think for those of you are interested, we're here to help and we'd love to see you. Dr. Mark Hyman(35:00): I think, Todd, you are just one of those incredible thinkers in functional medicine. You teach all over the world. Not anymore, all over Zoom maybe. I'm teaching from my office up in my house. And I'm just so thrilled that we get to have these conversations about problems that are causing so much needless suffering- Dr. Todd Lepine (35:18): Absolutely. Dr. Mark Hyman(35:18): And now we can really solve them. Thank you for joining us again on the Doctor's Farmacy. If you love this podcast, please share it with your friends and family on social media, leave a comment, we'd love to hear from you, tell us about your issues and how you've maybe found a way to help them and show everybody else what can be done and subscribe wherever you get your podcasts. And we'll see you next on the Doctor's Farmacy. Dr. Todd Lepine (35:38): All right. Great. Thank you, Mark. I'm going to end right there because there's really a wonderful video on YouTube. That's called the Big Pharma Rant. You probably have seen it with Bill Maher. It's a really good one. And he basically ends it by saying, cause in functional medicine, what we do is we try to get patients better so that we don't see them anymore. Dr. Mark Hyman(35:58): It's true. Dr. Todd Lepine (35:58): I'm trying to put myself out of business. Dr. Mark Hyman(35:59): It's true [crosstalk 00:36:00]. Dr. Todd Lepine (36:00): And what he says is, "There's no money in healthy people and there's no money in dead people, but you can make a lot of money in really sick people who are chronic-" Dr. Todd Lepine (36:08): Who keeps seeing you and they spend $50,000 a year on medications." Dr. Mark Hyman(36:13): That's the whole point. Dr. Todd Lepine (36:13): Absolutely. Dr. Mark Hyman(36:14): Yeah, no, it's true. But it's true. We definitely have the problem where we see people, we get them better and then we don't hear from them- Dr. Todd Lepine (36:22): Which is good. Dr. Mark Hyman(36:23): And then you go, what happened? And then five years later, they call about something else, "Oh, I was totally better. I'm cured. I don't know why. I'm fine." I just talked to someone like that yesterday, was like, "Oh wow. That's awesome." Dr. Todd Lepine (36:32): Yeah, it is. Dr. Mark Hyman(36:33): Anyway, thank you for joining us in the Doctor's Farmacy, Todd. Dr. Todd Lepine (36:35): Thanks.