Integrative Approach to Eczema with Dr. Julie Greenberg: Rational Wellness Podcast 205

Dr. Julie Greenberg speaks about an Integrative Approach to Eczema with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on April 22, 2021.

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Podcast Highlights

2:03  Like Hippocrates said, all disease begins in the gut.

2:22  The goal of Naturopathic and Functional Medicine is to look beyond the symptoms and the triggers to treat the root cause(s).  For dermatological conditions we can use topical steroids to treat their rash, but that’s not the goal of Functional Medicine.  We also don’t want to get stuck on triggers.  A trigger is something that can make the skin condition worse, like diet.  There are too many practitioners, esp. in the Functional Medicine world, get stuck on diet to treat dermatological disease.  While there may be a few conditions where diet is the root cause, like pediatric eczema, but for most derm conditions, such as adults with rashes, the root cause is very unlikely to be food.  Food is more likely to be a trigger and just eliminating those foods will be unlikely to clear up the condition.  Dr. Greenberg believes that Functional Medicine testing, esp. stool testing, organic acid tests (OAT), and urinary mycotoxin testing can be helpful in discovering some of the root causes of many derm conditions. 

4:54  Stool testing, like the GI Map, helps us to see both commensal (normal), opportunistic, and pathogenic bacteria in our microbiome. It also tests for fungi and yeast.  But it is not that reliable for candida, which is why Dr. Greenberg likes the OAT, which is better for identifying candida overgrowth.  A stool test will also look for parasites, like worms and protozoa, and for viruses. It will also give information about digestive markers, short chain fatty acids, inflammation, and intestinal permeability.

5:57  The organic acid test (OAT) is more complicated than the stool test and the one Dr. Greenberg orders from Great Plains Lab includes 74 metabolites from urine.  It includes yeast and fungal markers, and markers for bacteria, clostridia, and oxalates. It also looks at mitochondrial function and neurotransmitter metabolites. It takes more work and training to learn how to use the OAT test.

6:35  Mycotoxin testing.  Mycotoxins are toxic secondary metabolites of mold and can be found in urine.  The mycotoxins found most frequently are aspergillus, penicillium, fusarium, stachybotrys (the black mold), and chaetomium.

8:38  Up to 80% of our immune system comes from our gut.  If the gut isn’t healthy, the skin is not going to be healthy.  When you see someone with a skin problem, you should be thinking that’s somebody with a gut problem.

9:07  Immunology.  Eczema is a Th2 mediated pathway. Th22 is also involved in skin inflammation. Also, Th17 primes out immune system and it is also involved.

10:09  The gut affects the immune system.  Gram negative bacteria often produce endotoxins like lipopolysaccharides (LPS), which trigger an acute inflammatory response.  LPS also inhibits the liver’s ability to do its job and detoxify.  It can even cross the blood-brain barrier and promote neuroinflammation.  Gram positive bacteria can also stir up the immune system and create inflammation.  They contain a peptidoglycan layer and teichoic acid and lipoteichoic acid in their outer cell walls.  Staph aureus, which is a gram positive bacteria, is a major player in eczema.  Candida is also present in so many derm patients and it produces extracellular proteinase that breaks down collagen and keratin in the skin.  It can also break down the IgA complement and decreases IgA production.  Candida also increases vascular permeability and leaky gut.  Candida also weakens our immune system and makes it more difficult for our immune system to kill staph aureus and E. coli.

13:33  Leaky gut.  The bloodstream is right below this one layer of intestinal epithelial cells, which should have tight junctions that prevent large food molecules from getting into the blood.  There is a thick mucosal layer that helps protect the epithelial layer and secretory IgA is in this mucosal layer and it provides immune protection and it grabs onto pathogens and endotoxins like LPS.  When this mucosal layer is eroded, we will have a loss of the tight junctions and leaky gut.  There are two keystone species of bacteria that help protect against leaky gut and these are faecalibacterium prausnitzii and akkermansia muciniphila.  Akkermansia is mucin loving and while it eats a bit of this mucus layer it stimulates the goblet cells in our gut to produce more mucus.  Faecalibacterium is a butyrate producer, which is the main food for our intestinal epithelial cells, which turn over every 24 hours.  Butyrate also calms our immune system and enforces the tight junctionsl of the epithelial cells and helps to prevent leaky gut. We need to feed the Faecalibacterium with prebiotics or fiber.  Unfortunately, antibiotics can kill off good bacteria like faecalibacterium and akkermansia while it’s killing off the bad bacteria. Alcohol, NSAIDs, and a lack of fiber can also kill these two keystone species of good bacteria.

21:22  Eczema, aka, atopic dermatitis, is a disease of skin barrier dysfunction and inflammation.  While we see the inflammation in the skin, there is inflammation in the gut and the system.  We think of eczema as a Th2 mediated disease with its related cytokines, IL-4, 5, and 13.  But there is also a chronic phase of eczema where there’s increased levels of Th1, Th17, Th22, and related cytokines.  By treating the gut, we can treat all these types of inflammation.  Patients with eczema tend to have lower levels of beneficial gut bacteria like bifido and bacteroidetes and higher levels of pathogenic bacteria like C. diff, E. coli, and staph aureus.  Staph is often found in patients with eczema, including in the skin, the gut, and the nasal passages.  The staph suppresses IgA and IgG production in peripheral blood lymphocytes and increases IgE and histamine synthesis.  IgE is the Th2 pathway.  Many eczema patients also have candida overgrowth and when you treat the candida, the eczema will improve.

27:07  It can be helpful to use butyrate supplements, for adults one capsule three times per day with meals and for infants, one scoop mixed into milk or apple sauce once per day.

28:44  The first case study is Sam, who is an 11-month-old male with eczema.  His eczema started 2 months prior and 2 months after receiving pasteurized donor milk.  His mom has been using triple therapy cream on him, which contains triamcinolone, which is a steroid, nystatin, which is an antifungal, and mupirocin, which is an antibiotic. The triple cream worked at first and then it stopped working. This is typically what happens when they go to a conventional dermatologist. Then they will need a stronger and stronger steroid. Dr. Greenberg then ran a stool and an OAT test on him. When you look at the stool test, you might see C. Diff, which might be alarming in an adult, but is fairly common in infants.  Sam was low in certain healthy bacteria, including lactobacillus and two keystone species, akkermansia and faecalibacterium prausnitzii.  Akkermansia helps the goblet cells in our gut produce the mucus layer, and faecalibacterium is the main butyrate producer.  He has high enterococcus, which in adults causes a lot of UTIs.  He is high pseudomonas, which is a gram negative bacteria and a huge LPS producer.  Both staph and strep are also overgrown.  Eczema patients often have candida, but it often is present in the upper GI tract rather than the colon, so it may not show up on the stool test, which is why the OAT test is better for picking up candida.  Both citrobacter and klebsiella are present and these are bad actors, so we want to clear them out. Also, his secretory IgA is very low, so we want to support this.  When we look at the OAT we need to look at 7. Arabinose, which is the marker for candida, we see that Sam’s is very high.  So he has high candida, high staph, and high strep, which is often seen in eczema. But he also has high aspergillus, which is mold. He also has high oxalates, which you don’t need to treat, since it will come down if you treat the candida and the mold. When there is candida and mold you want to look at B2 riboflavin, which they will also often need, and she will give in drops for infants.  Dr. Greenberg will treat the bacterial overgrowth with antibacterial herbs and antifungal herbs that are safe for infants and a lactobacillus-bifido blend probiotic. She does not like using spore based probiotics for infants, since she has found that spore-based probiotics don’t play well in the guts of infants.  She also uses a new akkermansia probiotic that is available from Pendulum Probiotics and a prebiotic, Mega Pre from Microbiome Labs that helps to bring up levels of faecalibacterium prausnitzii and akkermansia.  She will also give butyrate supplements.  To bring up the IgA, Dr. Greenberg will use Mega IgG2000 or SBI Protect. 

Dr. Greenberg may use a botanical topical on the skin of patients with eczema, but this works best if it is acidic rather than alkaline.  The skin pH is supposed to be acidic but it is often alkaline in patients with eczema. If the skin becomes more alkaline, staph will really proliferate, so using things that are both antibacterial and acidic will be the most effective.  She may use things like colloidal silver spray or a mix of apple cider vinegar and water, but if the skin is really compromised, then apple cider vinegar will likely burn too much.  Rosemary hydrosol works well and is both antifungal and antibacterial.  She likes to use a neem oil that has a bit of peppermint and lavender essential oils. Sometimes she will make a salve with essential oils.

50:37  Sam’s parents agreed to run the mycotoxin test and it showed a lot of mycotoxins, including ochratoxin A from aspergillus and sterigmatocystin that’s specific to penicillium. Dr. Greenberg treated the mycotoxins with binders and glutathione and she adds fish oil, because mycotoxins are lipophilic. Then we have to have the family investigate the home to find out the source of the mold and remove it.

53:10  The second case study: Alice, a 39 year old with eczema.  She had eczema as a child and on and off as an adult, but the eczema on her neck got severe during her pregnancy nine months ago and she cannot sleep at night. A dermatologist prescribed tacrolimus, which is a topical calcineurin inhibitor, and crisaborole, aka, Eucrisa, which is a topical PDE4 inhibitor. These drugs are like steroids trying to suppress inflammation, but they are not working now. The fact that the skin is oozing indicates that there’s a staph infection. You should either refer them to a dermatologist or swab it and send it out for testing.  Dr. Greenberg ordered a stool test, which showed high H. pylori, which indicates that there is low stomach acid. Not only should we treat the H. pylori, but we also need to give HCL.  Low HCL can lead to overgrowth of dysbiotic bacteria like enterococcus and prevotella, and even SIBO.  Akkermansia is not found, which means no mucosal lining, which means leaky gut.  She also has overgrowth of methanobacteriaceae, which can cause constipation and methane SIBO.  There are two large groups of bacteria, the bacteroidetes and the firmicutes, and most of the inflammatory bacteria are in the firmicutes, which in this patient is overgrown.  Her pancreatic elastase is low and in Functional Medicine we want to see this level above 500, which means that she needs enzymes, so she will recommend digestive enzymes that also contain HCL and bile.  The stool test did not show candida, but we need to also look at the OAT test for this. She did show another type of fungus, geotrichum. When you have this much dysbiosis, it allows yeast and fungus to get a foothold.

1:00:25  Dr. Greenberg will not usually use enzymes with infants, but she may use the chewable enzymes with kids. There is no way to get bile into them, since you have to swallow a capsule and if you open the capsule, the taste is really bad.  For adults her favorite enzyme products are DuoZyme by Karuna and Panplex Phase 2 by Integrative.

1:02:11  Beta-glucuronidase.  This is an enzyme that is part of how the liver removes estrogens and certain toxins, in this case by attaching glucuronic acid onto the estrogen, so then it will be excreted through the stool.  Beta-glucuronidase is the enzyme that will cleave the glucuronic acid from the estrogen and this can lead to reabsorption of the estrogen back into the body, so this is a bad thing.  It can make women more estrogen dominant, so you might want to supplement with calcium d-glucorate, though since this patient is breast feeding, Dr. Greenberg will not give it.  Also she had a really low secretory IgA. On her OAT test she has high candida. Dr. Greenberg will treat the staph infection with topical antibiotics–Mupirocin ointment for a few days–and then she created an antibacterial essential oil salve for her. She used a natural protocol for H. pylori with mastic gum, etc., enzymes with HCL and bile, herbs for the bacterial overgrowth and the candida, akkermansia probiotic, the IgA supplement, and calcium D-glucorate. Her favorite anti-candida formula for infants is Biocidin liquid, since it’s broad spectrum, and it addresses a lot of things, clostridia, candida, bacteria, and it’s safe for most infants.  Also its in a glycerin base and you should not use formulas in an alcohol base for infants.  There is also a company, Beyond Balance, that makes liquid glyceride formulas, and these work well for kids.  For adults Dr. Greenberg likes Candida Support from Now. She also likes grapefruit seed extract, caprylic acid, and neem, depending upon the patient.  She does not like to use Saccharomyces boulardii, as some practitioners recommend, since it’s a yeast and she does not like to give more yeast when you already have yeast overgrowth.



Dr. Julie Greenberg is a Naturopathic Doctor who specializes in Integrative Dermatology. She is the founder of the Center for Integrative Dermatology in Santa Monica, California, a holistic clinic that approaches skin problems by finding and treating the root cause. Dr. Greenberg holds degrees from Northwestern University, Stanford University, and Bastyr University. She lectures at naturopathic medical schools and speaks at conferences across the US on dermatology. Her website is IntegrativeDermatologyCenter.com and her email is drgreenberg@integrativedermatologycenter.com.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.


Podcast Transcript

Dr. Weitz:                            Hey. This is Dr. Ben Weitz, host of The Rational Wellness Podcast. I talk to leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to The Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.

                                                I’d like to introduce our speaker for tonight, Dr. Julie Greenberg. Dr. Greenberg is a licensed naturopathic doctor, who specializes in integrative dermatology. She’s the founder of the Center of Integrative Dermatology in Santa Monica, a holistic clinic that approaches skin problems by finding and treating the root cause, but Dr. Greenberg sees patients now mostly virtually in various parts of the United States. Dr. Greenberg holds degrees from Western University, Stanford University, and Bastyr University. Dr. Greenberg, you have the floor.

Dr. Greenberg:                 All right. I’m going to screen share with you guys. Can you enable screen sharing for me?

Dr. Weitz:                         Oh, yes. There you go.

Dr. Greenberg:                 Okay. There we go. Okay. All right. So, thank you guys for joining today. I appreciate your time and I’m going to try to make the most of it. I know all of our time is very precious. So, this is functional medicine test for treating dermatology, and we’re going to focus on stool test and OATs or organic acid urine tests. You just heard a little bit about me, but I’m licensed naturopathic physician in California, Oregon, and Washington. I’m also a registered herbalist, and, yeah, my clinic, the Center for Integrative Dermatology is on Wilshire. I’m still there. Just right now for COVID practicing mostly virtually.   So, this guy may look familiar. He’s our old friend Hippocrates, and he said, “All disease begins in the gut.” If we were old school and still at the Santa Monica Library, I’d ask everyone who agrees with this statement raise your hand, and I’m sure all of our hands would shoot up because this is the functional medicine group and we know how important the gut is.  So, the goal of naturopathic or functional medicine, as we know, is we want to treat the root cause. There are triggers and symptoms. So, symptoms, we know especially in derm, somebody walks in, they got a rash, that’s their symptom, and we can do things like put topical steroids on it, but that’s not the goal of functional medicine.    At the same time, we want to treat root causes. We don’t want to get stuck on triggers. What a trigger is is something that can make it worse, but even if you eliminate it, it’s not going to fix the problem. I bring up triggers versus root causes because when we get to dermatology, particularly in the functional medicine and naturopathic world, people focus a lot on diet, and I have too many people who are really exclusive focused on diet to try to treat their derm disease.

                                                So, I’m going to pose a question, is diet the root cause of dermatological disease or a trigger?  Really, it’s usually a trigger.  There are some exceptions to this, pediatric, infant eczema that’s moderate to severe. There really can be food root causes, but in adults who breaks out on a rash, it is very unlikely to be food and people get stuck on it.  Can changes in diet affect dermatological disease? Absolutely 100%. I’m not saying diet doesn’t matter, but I’m saying it’s a trigger, and even if you eliminate those flares, if the skin condition doesn’t clear up, it was a trigger and not a root cause.

                                                So, why are we talking about functional medicine testing?  Why aren’t we just using conventional testing?  Again, I think everyone here knows the answer. We can run CBCs and CMPs, but we’re just not always going to get the answer.  A lot of times, they’re going to come back normal.  Your patient’s hair is falling out, there’s rashes all over the place.  That’s not normal.  So, these aren’t particularly helpful most of the time.  We definitely want to get to the root cause, so we aren’t just suppressing symptoms.  So, really, we have to run these tests to get there.

                                                I know there’s differing levels of knowledge of functional medicine, so I’ll just really briefly review it so that we’re all at a baseline. What are functional medicine tests?  There are so many and we can use all sorts of substances, urine, stool, blood, saliva, breath, DNA. Here’s just a sampling list of different types of functional medicine tests.  Again, there are just so many.  I know many of us here use a variety of these.  Today, we’re going to focus on stool testing and OAT or organic acid testing, and then we’re going to do a dash on mycotoxin testing.

                                                So, stool testing, again, in case you’ve never run one and you’re wondering what you get out of it, it’s testing for both pathogens and commensals. Three to five pounds of our gut bacteria lives in the colon. It makes it really convenient. We test the stool. That’s where it’s coming from. We see the bacteria. So, I like to see H. pylori. We want the normal, the opportunistic, and the pathogenic bacteria. It also tests for fungi and yeast. I have found it is not super reliable for testing for candida, which is very important in dermatological disease. That’s one of the reasons why I run the OAT is I find it a lot more reliable for testing candida and then other types of molds.  Stool tests will look for parasites, protozoa, and worms, viruses, and then a host of other things, digestive markers, short-chain fatty acids, which we are going to be talking about butyrate quite a bit, inflammatory markers, and intestinal permeability. You can test for zonulin. It is one marker of leaky gut.

                                                The OAT, organic acid test, is a little more complicated. There’s about, I think, 74 metabolites of the urine testing in the OAT that I use. It does do the yeast and fungal elements, some bacterial and particularly pathogenic clostridia, which we’ll look at, and then lots of other information that you can get.  In terms of being a practitioner using these tests, I think it’s much harder to learn how to analyze and use the OAT, but it is a very useful test. The stool test is much more straightforward because you’re looking at strains of bacteria or lists of protozoa, but this requires more training.

                                                So, mycotoxins, I mentioned that we’re going to touch on mycotoxin testing. Some of you may be wondering what’s a mycotoxin. Other of you may be mold and mycotoxin certified. Again, just to make sure we’re on the same page, mycotoxins are defined as toxic secondary metabolites produced by organisms of the fungus kingdom. In simple terms, what that means is that when certain molds feel threatened, that other mold or bacteria is encroaching on its face and it’s going to come and kill it. It has to fight back and it produces chemical warfare, and it creates these things called mycotoxins and shoots them into the air.   They are quite toxic and they can cause disease in both humans and animals. So, this is a big deal in livestock. They eat moldy grain and the whole herd can die, but it’s an issue for humans as well. Some of the molds that we look at in terms of mycotoxin production are aspergillus, penicillium, fusarium, stachybotrys or the black mold, and chaetomium. So, we’re going to look at little bit at some mycotoxin tests.

                                                Just to make sure, again, I know everyone knows a lot of gastro, but just to make sure we’re on the same page and so that the significance when we go do the case studies because we’re going to look at a pediatric and an adult eczema case, we’re going to look at their labs, before and after pictures, and how they were treated, I want you guys to understand what I’m assessing.  So, why are we doing a gastro review for a derm talk?  Well, we know that gut dysbiosis leads to systemic inflammation. No doubt about that. Systemic inflammation leads to chronic disease, and chronic dermatological disease.  For some reason, derm has been left out of the functional medicine world and even the naturopathic world. I’m one of the only specialists I know in the naturopathic world who specializes in derm, and it is so important and so tied to the gut.  So, I hope to prove that point out to you guys so that you think about derm problems in a different way after this talk.  So, we’re going to test and treat the gut to treat derm.  I won’t go into all the ways that our gut basically primes our immune system and all the crosstalk that goes. I think you guys know this, and we’ll be touching on some of these points, but there’s estimates saying 80% of our immune system comes from our gut, and it’s very real.  If the gut isn’t healthy, the skin is not going to be healthy.  Basically, when you see someone with a skin problem, I want you to be thinking that’s somebody with a gut problem.

                                                So, a little bit of a microbiome, actually, I guess this is an immunology review. So, we have T cells and cytokines that influence the immune system. When we look at T cells, when we first develop them, they’re called naïve because they don’t know what they’re going to be when they grow up. The body has to tell them, “Here’s the problem and this is what you need to become.”    So, I talk to patients and I say it’s like Army, Navy, Air Force, Marines. Where is the threat coming from and what kind of T cells do we need to attack that invader? So, when we look at different T cells, we typically think of eczema as a Th2 mediated pathway, and that is true, but we’re going to see that it is much more than that. Th22 is involved in tissue inflammation. So, any derm disease, any skin inflammation is going to be Th22. Basically, this is what’s priming our immune system, and Th17 is often involved. That’s mucocutaneous sites. That’s the gut. So, we’ll look at some of these pathways.

                                                So, I think we know that there’s some of the major influencers of our immune system from the gut would be bacteria, gram negative and positive, candida and molds, whether we have leaky gut, and even short-chain fatty acids. So, here’s a microbiome review. Just real fast, I think we focus a lot on gram negative bacteria and endotoxins. So, there are similarities, right? We have a peptidoglycan outer layer wall in gram positive bacteria, things like staph, strep, and clostridia.  We do have a peptidoglycan layer in gram negative bacteria, but what we really see is this outer cell wall of lipopolysaccharides, LPS. We refer to them as endotoxins. We focus a lot on these LPS endotoxins in this world, but I want to give a little screen time to the gram positives because they can get the immune system flared up, too.  In addition to the peptidoglycans, there’s teichoic acid and lipoteichoic acid in their outer cell walls. Staph aureus is a big player in eczema. So, I called this out particularly for today’s talk because if you have a patient with eczema, you do have a patient with staph problems and it’s a gram positive problem.

                                                So, all of these things fire up our immune system, great, and that ultimately leads to an uptick in complement and cytokines, AKA inflammation. So, if we dive a little bit deeper, we’d look at the LPS, lipopolysaccharides or endotoxins. We know that they trigger an acute inflammatory response in the body. It increases leaky gut. It inhibits the liver’s ability to do its job and detoxify. It can even cross the blood-brain barrier and promote neuroinflammation.  The gram positives cause problems as well. This teichoic and lipoteichoic acid in the cell walls, they cause a lot of issues in our immune system. They trigger neutrophils and macrophages and, basically, that leads to a cascade of inflammation as well.  The peptidoglycan layer fires up the innate immune system. We know that there’s relation to various autoimmune diseases, and it can even produce toxins. Usually, that’s a toxic shock syndrome. That happens less frequently, but the gram positives are not good players in our immune system just as much as the gram negative, even though I think we focus on LPS a lot more.

                                                Candida, we can’t forget about candida. It’s present in so many of my derm patients. It produces extracellular proteinase that breaks down collagen and keratin in skin. It also breaks down IgA complement, and we’re going to talk about secretory IgA in the gut. We’re going to see how deficient it is in some of my patients, and candida can be a cause of that. It erodes the mucosal layer in the stomach and, therefore, decreases the IgA production.  It also increases vascular permeability. Think leaky gut. We know that it compromises the immune system. So, there are studies that show a reduced ability of the body, of our leukocytes to kill staph aureus and E. coli in the presence of candida. So, I know that any of patient who has candida overgrowth, their immune system has been compromised and that’s part of why I’m going to be seeing all this other overgrowth and dysbiosis.

                                                Again, I know this crew talks about leaky gut and knows leaky gut, but just to make sure we’re on the same page, again, when we go to the case studies, I’ll take just a few seconds to talk about this. I think the easiest way of talking about a leaky gut is looking at a healthy gut. So, what we’re looking at here is a cross-section of the gut. These, of course, are the intestinal epithelial cells, and they’re stuck together with tight junctions so things don’t get through. Our bloodstream is right below our entire digestive tract because the whole point from mouth to anus of this GI tract is to digest food, break it down into very small pieces like amino acids, vitamins, minerals, get that into the bloodstream and send those nutrients out to every cell in the body.   So, of course, the entire GI tract has the bloodstream underneath it, and we have an immune system just at the ready in case something goes wrong. What’s happening up top here, it’s the hole. So, if you swallowed a plastic ball, we’re like a pinball machine. It’s just going to go through and you’re going to poop it out the other side. We have a hole, and three to five pounds of gut bacteria live up in this zone. Undigested food is up here. Then the critical part, of course, is this blue zone or strong mucosal barrier, whose job it is to separate the contents of our gut from these intestinal cells. These really need protection. They’re not too robust, and they can’t be in contact with all this.

                                                Secretory IgA, we’ll talk about a lot. I call it the Y guys to my patients. We see it grabbing on to LPS or endotoxin. It’s secreted by the mucosal barrier of the gut, and it helps us deal with the pathogens in the gut. So, we do want a good amount of secretory IgA.

                                                Well, leaky gut is what happens when the mucosal barrier is eroded, of course. Two specific bacteria we’re going to be talking about when we get to stool test are faecalibacterium prausnitzii and akkermansia muciniphila. Akkermansia, it’s in his name, mucin-loving. So, he actually eats a little bit of that mucus layer, but he stimulates these special cells in our gut, goblet cells, to produce more mucous. So, we want good levels of akkermansia to not have a leaky gut. We’ll talk about faecalibacterium in a minute, but he’s a butyrate producer. He does a lot of good for us. So, these are two keystone species I look for on every stool test.  So, over here when we get the leaky gut situation, how do we get in this situation? Antibiotics, it’s going to kill off good bacteria like faecalibacterium and akkermansia while it’s killing off the bad guys of the UTI or mastitis or whatever you’re taking the antibiotic. Also, we can get candida blooms when we take antibiotics and candida will erode that mucosal layer. Alcohol will do it, pathogenic bacteria-producing toxins, NSAIDs like Advil, and just a general lack of fiber, where we’re not feeding the good guys and they’re not there in the right amounts.

Dr. Weitz:                            How do we know if our patients have leaky gut? Is zonulin a good test for leaky gut or should we almost assume that most of our patients with dysbiosis probably have leaky gut?

Dr. Greenberg:                 That’s a great question. I used to run the zonulin test, but I’ve found that it’s just one marker of intestinal permeability. If it came up as not high, then my patients will be lulled into this false sense of security like, “Oh, I don’t have leaky gut,” which is not true.   So, I do assume that almost all my patients have leaky gut, but I’ll show you when I look at the stool test, I’m looking for that akkermansia muciniphila. Is it present in good numbers? Faecalibacterium prausnitzii, is it present in good numbers, and the secretory IgA.  When those three things are off, you can pretty much assume that your patient has leaky gut, whether or not it’s zonulin. So, I don’t even test the zonulin anymore, unless a patient specifically asks for it.

Dr. Weitz:                         Are there any other tests for leaky gut that are valid?

Dr. Greenberg:                 There are other gut permeability tests that-

Dr. Weitz:                         We used to do the lactulose mannitol permeability test.

Dr. Greenberg:                 Exactly, but, for me, I can get what I need out of the stool test and so I don’t have patients go do that.  Sometimes I’ll do a SIBO breath test in particular patients, but a lot of times I don’t have to.  Sometimes if it’s really bad, I need to determine is it hydrogen or methane or both, but I can also usually tell from the stool test whether or not they SIBO and potentially SIFO.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 So, we were looking at a cartoon of the gut and, of course, that’s really easy to draw. This is a stain of an actual gut. We can see the importance of the mucosal layer. So, this is the three to five pounds of bacteria. These are those intestinal epithelial cells stuck together with tight junctions. This is the mucosal barrier separating the two, creating a calm immune system.  If we start erasing the mucosa, and this bacteria floods the cells, that’s basically leaky gut, and now our immune system has to deal with this stuff. So, I really love the stain. Just to drive the point home, this is a rat gut, but it was a study that showed this very thick mucosal layer from the stomach all the way to the backend. We have a very robust mucosal layer in all mammals, and it serves a real function and without it, we’re in trouble.

                                                I mentioned faecalibacterium prausnitzii. He’s such a keystone species and so important to intestinal health because he produces butyrate. Butyrate is the main food source of our intestinal epithelial cells, and they turn over every 24 hours. We have so many cells that need food.   So, what we see here is that process of we feed the faecalibacterium prausnitzii with prebiotics or fiber. Faecalibacterium is the probiotic and it produces postbiotics for us or beneficial things like butyrate. Butyrate has benefits all over the body, but we do focus on it in the gut. So, it’s that preferred fuel of enterocytes. It calms the immune system, and it creates a calming effect. It enforces tight junctions and also helps to prevent leaky gut. So, this is a keystone species I look for.

                                                Then when I’m assessing GI function of my patients, I think about it in two buckets. One bucket is their digestive function. How is their stomach acid? Are they producing enough bile? Are there enough digestive enzymes? We can get this a lot from the stool test.   Then, of course, what is the microbiome? Is there H. pylori in the stomach that’s affecting the stomach acid? The stool test I use has H. pylori on every test because I need to see it particularly for derm. I’m assessing if there’s SIBO and just what kind of growth and dysbiosis is in there.   Of course, as a functional medicine and naturopathic provider, we treat the whole person. So, I’m really thinking about the microbial distribution on the whole body. We certainly talked about the GI tract, how important that is, but I’m also looking at, I’m checking their oral mucosa. Do they have root canals? Do they have bleeding gums? We swallow a liter and a half of saliva a day. That’s going into our gut. That’s going to impact our GI health.  Of course, the skin microbiome. We’re talking about eczema today, and I don’t really have time to go into it, but staph aureus is a huge player. It’s on the skin. It’s overgrown in the gut, and it’s in the airways. It colonizes the nasal passages. Even urogenital, so many of my female patients with candida overgrowth in the gut get vaginal yeast infections. So, we always are treating the whole person and thinking about the microbiome everywhere.

                                                So, let’s talk a little bit about eczema, and then we’ll get into the good stuff and dive in to case studies.   So, what is eczema or atopic dermatitis? Fundamentally, it’s a disease of skin barrier dysfunction and inflammation. We can see the skin barrier dysfunction and we see the inflammation on the skin, but it really is inflammation in the gut and in the bloodstream and the system as well.  When we think of eczema, we think of it as a Th2 mediated disease with these Th2 cells that we looked at and related cytokines, IL-4, 5, and 13, but we now know that there’s a chronic phase of eczema where there’s actually increased levels of Th1, Th17, Th22, and all those related cytokines, and anytime you get any sort of skin barrier disruption, you’re going to get additional cytokines that are released. So, you can see that when it comes to eczema, there’s just a whole world of inflammation going on.

                                                There’s a fascinating study that was done because eczema tends to be this catch all bucket. If you have a rash, they call it eczema, and everybody’s in the same group, but dermatologists and people who specialize in derm, we know that they’re actually different, and there are actually subtypes of eczema.   This brilliant study done in 2019 divided up groups of people eczema. There was three adult groups, a pediatric, and then they were comparing it to psoriasis as showing. Psoriasis is a completely different disease. Too often, I have people come in, “I don’t know if I have eczema or psoriasis.” It matters which you have. They are two totally different diseases with totally different pathophysiologies. Even in eczema, we need to know who our patient is.   So, we can see that they took European-Americans, Asian-Americans, African-Americans, and then pediatric groups. What we see is quite fascinating. When we look at these immune pathways, they’re all Th2 for eczema, right? We know that. That’s the classic pathway we associate with eczema. In contrast, we can see psoriasis not a Th2 mediated pathway, none whatsoever.   There’s really interesting part and Th22 we said is in barrier disruption. So, any derm disease count Th22, and you can check that box. When it comes to Th17 and Th1, psoriasis is a very heavy Th17 mediated disease, but the interesting thing is it’s really present in pediatric eczema and it’s present in Asian-American eczema, but it seems to be absent in African-American eczema. So, it really does matter who you’re treating, and there are endotypes.

                                                Now, the good news is by treating the gut, we’re going to treat all of these types of inflammation, but we do want to keep in mind underlying pathophysiology. When we look at published research, so I gut test all of my patients and I can attest to this, but you don’t have to take my word for it. There’s lots of published research that shows that when you have a patient with eczema, they tend to have lower levels of the beneficial gut bacteria, bifida bacteria, bacteroidetes, bacteroidetes and higher levels of pathogenic bacteria, C. diff, E. coli, staph aureus. We’re going to keep saying staph aureus in eczema, and they have GI diseases in higher amounts than normal healthy controls.  I briefly touched on this, but staph is going to be all over your eczema patients. It’s going to be in the nose, on the skin, and in the gut. It colonizes the nasal passages, and so you have to treat them. We talked a little about this teichoic acid from the gram positive bacteria. It’s sticking out of that peptidoglycan layer. It suppresses staph. It’s gram positive, and this teichoic acid suppress IgA and IgG production in peripheral blood lymphocyte from eczema patients. Exposure to the staph aureus cell wall containing the teichoic acid or peptidoglycans led to increased IgE and histamine synthesis, two very big problems in eczema, IgE is elevated, that’s the Th2 pathway and histamine. So, again, I never want to ignore my gram positive bacteria because they can wreak havoc even in addition to the gram negative LPS ones.

                                                Candida is definitely a huge problem in eczema patients. They have statistically significant higher levels of antibodies to candida albicans. They’re pretty much colonized with it. When you treat the candida in your eczema patients, the skin will improve.

                                                Leaky gut, again, you don’t have to just take my word for it. It’s in the published literature that patients with eczema appear to have increased intestinal permeability, and there is an association between the level of increased permeability and the severity of the eczema. The worse your gut, the worse your eczema is going to be. This is absolutely true.

                                                We mentioned short-chain fatty acids like butyrate. Do they matter? They do. This whole study is called severity of atopic disease inversely correlates with intestinal microbiota diversity and butyrate-producing bacteria. So, we talked about faecalibacterium prausnitzii is one of the main butyrate producers. The study found infants who are healthy or have mild eczema have higher levels of this butyrate-producing bacteria compared to those with severe eczema. Remember, butyrate, these are intestinal cells, enhances tight junctions, and decreases inflammation. It decreases leaky gut.

Dr. Weitz:                            So, since there’s no supplements of prausnitzii faecalibacterium, I butchered that name, sorry, but is it best to try to increase butyrate production by using the appropriate prebiotics or is it more helpful to use butyrate supplements?

Dr. Greenberg:                 Yeah, and we’ll get to this once we get to my treatment plans. I do start off supplementing with butyrate because I want to come in and make a big impact immediately, and I find that it really, really helps my derm patients, their gut, and the skin issues. So, I give them the butyrate, but definitely, obviously-

Dr. Weitz:                         What’s an appropriate dosage for butyrate?

Dr. Greenberg:                 Well, so the products I use I do one cap. For adults, I do one cap three times a day with meals, and for infants, there’s a little scoop of powder that they’ll put in to milk or mix it into apple sauce, depending on the age of the kid. So, actually, I don’t know the micrograms or the actual numbers. I just know what I dose.

Dr. Weitz:                         Okay. Thanks.

Dr. Greenberg:                 Yeah, but then to your point, we don’t want to keep somebody on a butyrate supplement forever. That’s not treating the root cause. So, we treat the gut dysbiosis, and I do then go use the prebiotics that are going to try to increase the akkermansia and faecalibacterium, and we’ll talk about akkermansia because there is a probiotic on the market now for akkermansia, but, yeah, I’m not aware of the faecalibacterium prausnitzii probiotic at this time.

                                                So, okay. So, let’s hop in to the interesting stuff, the cases, now that we’re all on the same page. So, our first case study is Sam. Sam is an 11-month-old male with eczema who came to see me. I think you can see the eczema. It was on other parts of the body as well, but the face was the worst. His eczema started two months ago when he was nine months old. He’s always had dry skin.  It was interesting. It started a few months after receiving pasteurized donor milk. I do hear this story not infrequently, and it begs the question, was it really pasteurized? What happened? Is it other things in the milk? We don’t know the answers, but this is not an infrequent story that I hear.  Mom has been using triple cream on him. This is a prescription given by a dermatologist including triamcinolone, which is a steroid, nystatin, which is an antifungal, and mupirocin, which is an antibiotic.  It’s not working anymore.  If any of you guys see eczema patients, you will hear this story over and over again.  If they go to a dermatologist first, they’re going to get a steroid or a triple cream. It is going to work at first, and then they’re going to need more and more and more and stronger steroid, and stronger steroid, and it’s going to stop working eventually, and then people will often try to come to people like us in functional medicine to offer them something that’s not just a tube of steroid cream.   So, my next steps are going to be I got to test his stool and his urine.  I’m going to run a stool test and an OAT.  So, we’re going to go through some of Sam’s results.  So, we see, first of all-

Dr. Weitz:                         Let me just ask you real quick. Somebody asked, “What’s the minimum age that you could do a stool test?”

Dr. Greenberg:                 I don’t know that there is a minimum age. I treat infants as young as four months with eczema and we do test them, but I am going to discuss here that the microbiome of infants is different than the microbiome of adults. You have to assess them in different ways. So, if I got this on an adult, this would be a lot more alarming than on a kid because we see it’s C. diff, C. diff that’s capable of producing toxin A and B. This doesn’t mean that it is producing that. If it was, your patient would be having bloody diarrhea. So, this would be a lot more alarming in adults.  We often see, for example, C. diff in infant microbiomes. We’re not sure how it gets there or why it’s there, if the microbiome is just trying to sample everything. So, this isn’t super alarming. I mean, I’m still going to treat the C. diff, but it’s not like, “Oh, my God! This baby has C. diff. How did it happen?” A lot of the infant stool test will come up with C. diff. So, you do need to get used to assessing infant microbiome and understand that it’s different than the adult microbiome, but I’ll do it on the four-month olds.   Okay. So, we just talked a little bit about C. diff. Yeah, I’m going to treat it, but it’s not as alarming as it would be as if Sam was an adult because it’s just often there.

                                                So, when we look at the normal flora, there’s a couple of things. First of all, this stool test puts clostridia in the normal flora. We already know there’s clostridium difficile. That’s a pathogen. So, we take these normal flora with a grain of salt, right? There’s good and bad within a lot of these different groups. So, that’s the first thing. It came out here that there’s C. diff, but the OAT test for pathogenic clostridia. So, I always look at the OAT to see what levels of pathogenic clostridia are part of this number.

                                                What we can see here is a mix of things. So, Sam is overgrown on certain types of bacteria. He’s low on lactobacillus, which is not rare for eczema patients. We can see when I go those keystone species for akkermansia and faecalibacterium, a lot of times I will see none for either. This symbol means below detectable limits. They didn’t find it. That’s good for the pathogens like campylobacter. It’s not good for faecalibacterium or akkermansia. We want to see good levels. How we read these values are this is 1.28 times 10 to the second power. So, we read this as 128, and the range of akkermansia is one times 10 to the first power or 10 ranging to five times 10 to the fourth power or 50,000.  So, he’s got 128, but the range goes up to 50,000. This is way too low akkermansia. We need akkermansia to be higher and we certainly need faecalibacterium prausnitzii to be higher. Again, akkermansia helps our gut, our goblet cells produce the mucus layer, and faecalibacterium is that main butyrate producer.

                                                Then when I get to the section for his dysbiotic bacteria, we can see a lot of stuff, enterococcus faecalis and faecium. So, in adult females, this causes a lot of UTIs. Pseudomonas is a gram negative. This is a huge LPS or endotoxin producer. So, when we are talking about endotoxins flooding the system with a leaky gut, pseudomonas is not one that we want to see.

                                                I will tell you that for my different types of dermatological disease, I see different patterns of these results. So, when it comes to my eczema patients, there’s three things that I expect to see. I expect to see staph aureus is high, and we’ve talked about staph aureus a lot. You saw it in the published literature that staph aureus is overgrown in the gut. You see it on this patient. I know it’s on his skin, and I know it’s in his nose, and strep. So, staph and strep are usually overgrown and candida is usually overgrown.

                                                Sam’s stool test did not show high candida, and this is as I talked about part of the reason why I used the OAT. Candida often will grow up in the small intestine. It doesn’t always show up on the stool test because, again, the stool test is from the backend, the colon. So, just because the stool test doesn’t have a high candida reading, that’s meaningless to me. I have to go look at the OAT.   So, right now, he’s two for three. He’s high on staph and high on strep, and that’s typical of my eczema patients, but they’ve also got other stuff, which is why I need to test them, and we can see he’s got a lot of pseudomonas and other overgrowth that needs to be addressed.  He’s got growth of citrobacter freundii and klebsiella pneumoniae. These are not good guys. These are in the potential autoimmune triggers. This does not mean that Sam has or will develop autoimmune disease, but these bacteria are associated with certain autoimmune diseases like klebsiella is associated with ankylosing spondylitis, for example. So, we don’t want them around. We want them to be less than detectable limits, and I want to clean all of this stuff up in him.

                                                His secretory IgA is low. If you remember, I said that was the Y guy on that picture. The Y guy was grabbing onto the LPS. So, you see we got tons of pseudomonas. That’s LPS and other ones. We need a good level of secretory IgA to help him cope with this, and he’s low. This is one of those markers. So, the three things I said I’m looking for leaky gut, two little akkermansia, two little faecalibacterium, and low secretory IgA. I can absolutely, even though I was suspicious that Sam had leaky gut, he absolutely has leaky gut now and there’s no doubt about it. So, his secretory IgA is 54. That’s a 10th of the lower limit of the scale. We want 500 to 2,000, really, to be healthy.

                                                So, now, I got to his OAT test. Now, we see a whole other world, which is the fungal world. If you just pay attention to the bacteria, you’re really doing your patients a disservice. I think this is what happens in SIBO a lot is that they’re testing and treating for bacteria and not paying attention to the fungal world. It’s huge.  So, what we see on his OAT test, the first marker I go to is seven arabinose. That’s the marker for candida. We can see his absolutely high. He has three times over the upper limit of what we want to see in candida. So, he’s just fulfilled the trifecta in my eczema patients, high candida, high staph, high strep, and other things.   What’s concerning on this OAT is these aspergillus because this is mold. Candida is yeast. It’s a single-cell fungal organism. Aspergillus is a mold. We don’t want to see mold overgrowing in him. The question is where is this coming from because candida is actually commensal. We all have candida. We just don’t want it overgrown, but we shouldn’t have aspergillus. So, there’s exposure coming from somewhere. So, we’re going to have to detangle that. Now, my hackles go up for mycotoxins. Am I worried about mycotoxins in this infant? We’ll see how I assess that and what we do with it.

Dr. Weitz:                            I just wanted to comment that I’ve seen a lot of times with patients who end up having mycotoxins and they also are dealing with fungal overgrowth.  What exactly is the relationship between those and how do they interact?

Dr. Greenberg:                 Yeah. It’s intimately connected. So, at the beginning, when I talked about those mycotoxins, mycotoxins are produced by mold. So, you’re not going to have mycotoxins without mold. Mold is two problems. One, is the mold growing in the system? This test is showing yes. He has actual aspergillus, fuzzy mold growing in his system. Then the second question is, is that mold producing mycotoxins? We can be affected by mycotoxins either by mold growing in our gut or mold growing in the environment.   So, I think people look around their house and say, “Well, I don’t see mold. I don’t live in a moldy environment.” You don’t actually really know that unless you come in and have full inspectors or rip up the walls because you’re doing construction. Mold hides behind the wall. It eats paper. It eats wood. That is what we build our homes out of, and all it needs is just a little bit of water, and it’s off to the races, and there can easily be tons of mold growing behind walls. If that mold is feeling threatened, it’s going to start pumping out mycotoxins. So, they are intimately related. You don’t have mycotoxins without mold.

Dr. Weitz:                         Thank you.

Dr. Greenberg:                 Then when we look down here, we see the bacteria markers from the OAT. They’re all overgrown, but we already knew this from the stool test and from the stool test, we know the specific strains of overgrowth that are driving these numbers, but these are two different labs. One is urine, one is stool, and they usually do back each other up, which is nice to us providers to feel like the labs are valid.

                                                So, I want to point out that there are patterns that you learn to recognize on the OAT. So, for candida, once I see that there’s candida overgrowth, I’m specifically looking at two other markers, the oxalates and the vitamin B12. So, let’s look at his. Sam’s oxalates are high. This is because candida and mold kicks off oxalic acid or oxalates. So, when I have patients who have candida overgrowth and high oxalic acid, I don’t do anything to treat the high oxalates. I treat the candida and the oxalic acid will come down.   I mean, there are foods that are high in oxalates, but they’re healthy. It’s spinach and Swiss chard. So, unless someone is really going crazy like eating massive amounts of spinach, I never take away the high oxalate foods. I just treat the candida and mold, and this will come down naturally, but expect to see it and know where it’s coming from.

                                                Then the second is vitamin B2 or riboflavin. Candida and mold create acetaldehyde. If you have ever had too much alcohol one night and the next morning you woke up and had a hangover and felt terrible, you know what acetaldehyde is because that’s what pretty much poisoned you the next morning. So, candida and mold produce this and we use up our vitamin B2 trying to deal with it. So, I do supplement patients with additional B2 while I’m treating the candida and mold because I want to help them out. Again, they don’t need to be on B2 forever. We’re going to clean up the candida and mold and then they’re not going to need vitamin B2 supplementation. So, look for those two when you see candida.

                                                Then I need to look at the indicators of detoxification. I know he has mold growing in his gut, and now I need to try to figure out, do I think mycotoxins are a problem for this kid? Two of the ones that I look at are glutathione and this methylation toxic exposure.   So, his glutathione needs are not elevated yet, but he’s 11 months old. So, we may not have just depleted it yet, but if we keep going with all this overgrowth, he is going to be deficient in glutathione, but this toxic exposure methylation, this 2-hydroxybutyric marker is elevated, and that really worries me when it comes to somebody who’s got aspergillus overgrowth because my number one suspect for the toxic exposure is mycotoxins. So, in this case, I would recommend to the parents that they do a separate mycotoxin urine test to make sure either this is a problem or it’s not a problem, and we need to fix it or we don’t have to worry about it.

                                                So, we look at all of these issues for Sam, and we’re going to have to deal with all of them. Again, this is to treat the eczema. So, he’s got massive bacterial overgrowth of both commensals and dysbiotic bacteria. So, I need to treat with antibacterial herbs that are safe for infants. So, we’ll talk about it or if you’re an MD and you want to prescribe pharmaceuticals, then that’s your path. I really rely on herbs much more. There are occasions where I’ll prescribe antibiotics, but 95%-99% of the time I’m using herbs.

                                                I do give probiotics. I’m a huge fan of spore-based probiotics, but not in infants or breastfeeding moms. So, this infant would be getting a lactobacillus-bifida bacteria blend. I just find the spore-based, they just don’t play well in the guts of infants and even through the breast milk. I just get complaints from mom that the poop is this and it’s that. It just doesn’t happen with the lactobacillus and bifida probiotic. So, those are the type of probiotics I give infants.

                                                Then he had massive fungal overgrowth. He’s got candida and aspergillus and elevated markers of detoxification. So, we have to start investigating the source of the mold. Where did he get this aspergillus overgrowth in his gut? Is it coming from his home? I had one parent, not this infant, but another one who opened up the bottles and there was hidden pockets in the bottles and she found this black disgusting mold in there, and the infant was overloaded with molds. So, we have to figure out where it’s coming from.  This is related to testing the environment. So, you can do mold plates, which are agar plates, ERMIs, which are dust collections or call in mold inspectors, which are the best, but certainly the most expensive.  Then we need to treat with antifungal herbs safe for infants. So, a different protocol, and I don’t have an eczema protocol because I’m treating on the dysbiosis that I see in the gut.  Then I recommended the mycotoxin testing, and we’ll take a look in a minute, and an anti-candida diet. Now, he’s 11 months old. He’s not eating that much stuff, but we’re going to limit fruit and sugars and things like that because we don’t want to be feeding the candida while we’re trying to address it with herbal protocols.

                                                So, there’s no faecalibacterium prausnitzii, we discussed it, I am going to give a butyrate supplement. There’s a powder for infants and capsules for adults, and then eventually work on feeding prebiotics that will help the faecalibacterium come back. The akkermansia, there are probiotics that are available that now contain akkermansia. They came out last year. So, the good news is akkermansia is available. The bad news, it’s $200 a bottle, and they’ve been back ordered, so it takes a few months to come.  I called the company and asked if it works for infants or children to open the capsules if the akkermansia will survive, they’ve never tested it. They don’t know for sure. So, I do tell the parents that because it is $200 a bottle, but the company feels like it’s worth a shot as long as they eat it right away. So, I will give the infants this akkermansia.

Dr. Weitz:                         What’s the name of the company that sells this?

Dr. Greenberg:                 It’s called Pendulum Probiotics. It’s marketed as a diabetic, a glucose control one because as it turns out, diabetics have no akkermansia muciniphila, and leaky gut, and chronic inflammation. I think that’s why they priced it at $200 a bottle, but, yeah, it’s a glucose control, but it’s akkermansia and beneficial clostridia.

Dr. Weitz:                         Are there certain prebiotics that would stimulate the growth of akkermansia?

Dr. Greenberg:                 Yeah. I mean, I know MegaSpore has been on here and people use it. They have a Mega Prebiotic that they claim helps enhance the growth of faecalibacterium prausnitzii and akkermansia muciniphila. So, I haven’t looked at their studies, but I do use the Mega Prebiotic because they made those claims and I do find it’s a nice prebiotic.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 So, for the low secretory IgA, of course, this is due to the leaky gut, but, again, while we’re waiting, I’m going to give a supplement that has IgG, IgA, and IgM because we’re not going to fix the gut overnight, and there’s so much dysbiosis, and especially as we start to kill off this dysbiosis, we need that secretory IgA to be there to capture the LPS and gram positive and all of this stuff. So, I just give it as a supplement when I start.  We talked about his need for-

Dr. Weitz:                         Is there a particular product for IgA, IgG, IgM that you like?

Dr. Greenberg:                 So, again, I do use Mega IgG2000 in adults, and in infants, we just open up the cap. That’s the one I tend to use, but there’s others. There’s SBI Protect and some other ones as well.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 Then we talked about this need for vitamin B2 or riboflavin. He is deficient in it because of the candida and mold. So, I’m going to go ahead and give him, for infants I do drops of vitamin B2. For adults, I just do one cap a day of a vitamin B2 supplement while we’re treating the overgrowth.  Then, again, we don’t have time to get into it in this lecture, but I’m obviously addressing the skin barrier disruption, the staph aureus on the skin. I use natural botanical topicals, no steroids, no antibiotics, nothing like that.

                                         Okay. So, let’s look at what happens. So, this was baby Sam when he first came to see me and three weeks later. We can see. So, he’s not totally cured of his eczema, but it’s a lot better even three weeks later. He’s not itching as much. Your eczema parents are suffering as well the children. They’re watching their children suffer, and they’re kept up all night because the child is up all night scratching and itching.   So, he’s gone from a situation where he wasn’t able to sleep. The kids will scratch themselves until they bleed, and then they risk infection because the pain of scratching themselves until they bleed feels better than the itch. They’re this tortured by the itch of eczema. So, already, I mean, he’s not looking perfect, but he’s no longer awake and itching and on all of that stuff.

Dr. Weitz:                         Can you name a topical botanical cream that you like?

Dr. Greenberg:                 Yeah. It’s not like one thing, unfortunately. With naturopathic medicine, there’s no tube of magic cream like the steroid. It’s a whole thing, and I lecture on this at conferences and other situations, but you have to address the staph aureus on the skin. The staph is high pretty because the skin pH is off. The skin pH is supposed to be acidic, and when it raises and it becomes more alkaline or neutral, staph aureus will grow out of control. So, I’m doing things that are naturally antibacterial, and also will create an acidic pH on the skin. So, things like colloidal silver spray, antibacterial, a mix of apple cider vinegar and water, it is so acidic. Staph hates it. The problem is when the skin is really compromised, you’re not going to be able to use the apple cider vinegar because it’s going to be too stingy, but as the skin starts to heal up, then you can get in there with the apple cider vinegar and whack the staph down.

                                                I use hydrosols, which are water-based plant extracts. I love rosemary hydrosol. It’s antifungal and antibacterial. Depending on what’s going on, we’ll use different topicals. There’s a neem oil I like that has a little bit of peppermint and lavender essential oil. Peppermint essential oil is good for soothing the itch. So, we get a two for one, but there’s lot of things. Sometimes I’ll make a salve with essential oils or instruct the parents how to do it. So, it really depends, but a combination of topicals that are going to be antimicrobial, and pull that skin pH back down again to acidic.

Dr. Weitz:                         Is there a benefit to use some phototherapy for eczema?

Dr. Greenberg:                 I mean, people do find some benefit from red light therapy. At a certain place when people are suffering, anything you can do to ease the suffering, but I don’t find that I need it. They’re expensive machines. It’s time-consuming. It’s hard to get an infant to sit still in front of a red light machine. I find that I don’t need it most of the time. So, again, it is controlling symptoms, but it’s not actually getting to the root cause. So, I’m much more focused on let’s just clean this thing up.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 Okay. So, the parents agreed to run the mycotoxin test on Sam, and what we see is he’s got a lot of mycotoxins. So, there’s two things going on here. We already knew that he had aspergillus overgrowth in his gut, and ochratoxin A is going to be your most common mycotoxin that you see on any test because aspergillus is the most common mold. He’s got a massive amount of ochratoxin A. It’s seven, eight times the limit. So, there’s a green zone because we live on the planet, we eat food, food can have mold and mycotoxins. The only totally clean mycotoxins I see are the infants. So, just having a little bit in the green zone is not concerning, but these are concerning levels. His aspergillus is producing mycotoxins, and we need to get rid of the aspergillus in his gut at the source and deal with the mycotoxins.   There’s something else. So, penicillium is another kind of mold that produces mycotoxins. The OAT, unfortunately, only tests for aspergillus and fusarium molds. It doesn’t test for penicillium. So, we didn’t know that he had penicillium overgrowth or was being exposed to penicillium in the home, but, indeed, he has mycotoxin sterigmatocystin that’s specific to penicillium. So, there’s two molds, two mycotoxins, and this is absolutely creating immune suppression and exacerbating his condition.

                                                So, we have to treat the mycotoxins. We treat with binders. I add glutathione. I add fish oil because mycotoxins are lipophilic. So, the skin and the organs are lipophilic, but we want to give some fish oil like those mycotoxins find in the fish oil. Then we definitely have to do that home investigation and figure out where is the aspergillus and penicillium that he got exposed to because this is an 11-month-old infant. It narrows it down. It’s COVID, he’s not going to daycare. He doesn’t get up and go to work every day. He’s not sitting in a car for hours in traffic. It’s a home environment, and that’s what we need to figure out.  So, I think it’s important for people to get mold and mycotoxin training to become mold and mycotoxin literate before you try to treat patients. We’ll talk a little bit about that, but these are some foundations of treating mycotoxins.  So, at the initial visit, we see Sam. Three weeks later, much better, and then two months after that, the eczema has basically cleared up and everyone was happy. Okay.

                                                So, now, we’re going to look at the second case study. This is an adult with eczema. So, we looked at our pediatric eczema. We going to now look at adult eczema. This is Alice. Alice is 39 years old. She had eczema as a child. She’s had occasional eczema on and off as an adult, but her neck went really crazy during her pregnancy about nine months ago. She cannot sleep at night. This thing is itching and oozing. It’s just torturing her all day and all night.  Her baby is now four months old. She’s a breastfeeding mom. A dermatologist prescribed tacrolimus and crisaborole. Tacrolimus is a calcineurin inhibitor. It’s a topical cream. Crisaborole is also known as Eucrisa. It’s also a topical cream, a PDE4 inhibitor. So, both of these things are like steroids trying to suppress the inflammation, just shove it back down into the skin, which is clearly not working.

                                                So, my next steps are I’m going to give her a stool test and an OAT test, but I want you to note, this eczema has a secondary staph infection, and this happens a lot in eczema patients. You’re not just treating eczema. They’re staph way overcolonized and actually infecting. The keyword here that should clue you in that there’s a staph infection that needs to be addressed is the oozing. Once you get to the point when something is oozing, you could pretty much figure you got an infection.   You can send them to a dermatologist or if you can, swab it yourself. You need a wet sample. I don’t even do it. I just assume it’s staph and it needs to be treated stronger like a staph infection instead of just the colonization that we see in typical eczema.   So, let’s look at Alice’s stool test. So, she actually has high H. pylori, and once I see H. pylori, now my red light is flashing. Is this impacting the stomach acid? Is she having hypochlorhydria or too low stomach acid.  Is she not digesting her food properly?  Is this leading to overgrowth of commensal and dysbiotic bacteria and potentially SIBO? So, we have to go on.  When we look at her normal bacteria, we do see overgrowth of enterobacter, which in high amounts can be inflammatory. That akkermansia, not found.  No akkermansia, no mucosal lining.  I’m already basically diagnosing her with leaky gut. Her faecalibacterium prausnitzii was actually in the range, so not too bad. So, the bacteroidetes and the firmicutes are the big groups of bacteria. Together, they’re about 80% of the gut bacteria, and she’s high on this whole group firmicutes. So, there’s a lot of overgrowth of normal bacteria in there.  Usually, this is the more inflammatory class.  So, if one of them is going to be overgrown, usually it’s going to be the firmicutes like hers is.  When we look at her dysbiotic bacteria, we also see a lot of overgrowth. Again, we see strep is overgrown and staph is present in her. She’s also got this enterococcus, and prevotella, and methanobrevibacter, which can cause constipation. We definitely don’t want constipation in these patients. We want them moving out all the stuff on a daily basis, but these produce methane and it paralyzes the gut.

                                                Then, again, her candida stool test did not show that she had a candida problem, but I got to wait and look at the OAT. There was this other type of fungi or yeast, the geotrichum. I will see this on the stool test. There’s another one, rhodotorula, that can show up. Basically, when you’ve got this onslaught of dysbiosis, it allows these yeasts and fungi which we should normally be able to clear to get a little foothold. So, it’s not unusual to see other little yeasts pop up as well like this and the rhodotorula.   Then when we look at her digestive health, so her elastase is low. In functional medicine, we actually want to see this over 500. She’s definitely low. One of my number one reasons why I see elastase low is that there’s high H. pylori. The stomach acid is now hypochlorhydric, and the pancreas is not getting the strong enough signal to produce the pancreatic enzymes. So, this tells me that she is hypochlorhydric, and I need to be worried about not just treating the H. pylori but also dealing with the enzymes.   Her beta-glucuronidase is high normal.

Dr. Weitz:                         By the way, how do you deal with the enzymes?

Dr. Greenberg:                 I will talk about it, but there’s an enzyme that contains HCL because I want to raise that stomach acid, and that’s hydrochloric acid, enzymes, and ox bile. I like the ox bile. Even though her steatocrit was not elevated, so she is digesting her fats. Bile is antibacterial and antimicrobial. So, it’s actually really beneficial to give that extra bile when they’re eating because that’s when they’re going to get the flood of LPS and endotoxins is when we eat, and those tight junctions have to open up so we absorb food. So, I like an enzyme that has HCL, enzymes, and bile.

Dr. Weitz:                         You just showed on previous test how the methane producer was high, and that’s one way that you could potentially diagnose SIBO. What are the other ways you can potentially diagnose SIBO through a stool test?

Dr. Greenberg:                 So, obviously, we want symptoms in SIBO, right? So, we’re going to start with, is there the gas and bloating? Are they having the GI symptoms? Because I think, and it will be interesting to see if Mark Pimentel talks about this when you have him back on. There was another talk I listened to where basically, now, whatever the SIBO breath test show, if they don’t have symptoms, it seems like now we don’t diagnose them with SIBO, that they have to be symptomatic.

                                                So, I take that to heart. Are they having any any GI symptoms? If they’re not, I’m not going to diagnose them with SIBO, but if they have the gas and bloating and all the rest of it, then the H. pylori is going to be your first clue because we know H. pylori is related to SIBO because of this hypochlorhydria and we swallow a liter and a half of bacteria a day, we eat food with bacteria and mold, and if the stomach acid is not acidic enough to kill off most of those bacteria and fungal elements, first stop is the small intestine. What a great place to set up shop, right? There’s no competition. You’re already here. So, we know that H. pylori and SIBO are related.   So, if I see H. pylori, and then I see, is there overgrowth of commensals, especially down here in the phyla group, and is there a lot of overgrowth of dysbiotic bacteria, and particularly, is there constipation? Is the methanobrevibacter high? There has to be symptoms for me. They have to be constipated. They’d had to have all of the SIBO-type presentations, but that’s how I use it.

Dr. Weitz:                         Good. Thank you. Somebody asked, “Can you use pancreatic enzymes in infants?”

Dr. Greenberg:                 I tend not to do it because a lot of times they’re on milk and other things, and I feel like it will work itself out. So, I tend not to give them. I mean, in kids, there’s the chewable enzymes, so depending on the age. I tend not to give it in the really tiny infants, but in the ones that can chew, I might give them the chewable enzymes. There’s no way to get the bile into kids because you have to swallow a capsule. I’ve tried opening up capsules and tasting bile to see, is there anything we could hide the bile in? It is so revolting. I almost vomited.

                                                As a naturopath, we’re pretty immune to most of these tastes. I can take almost anything. The ox bile was too much for me. No one is going to be able to take ox bile if it’s not in a capsule that they’re swallowing. So, there’s no opportunity for that, but I will give chewable enzymes to kids, but in infants, they’re usually doing a lot of milk. I mean, we might need to talk about their supplement if they’re not on breast milk and get them off of the dairy supplement. I tend not to give enzymes until they start getting to the chewable phase.

Dr. Weitz:                         Can you use bitters to stimulate enzymes?

Dr. Greenberg:                 Absolutely. So, a lot of times, I’ll start off with the stronger HCL, enzymes, and bile, and then as the gut is improving, switch to bitters because the bitters are a lower forced intervention. It stimulates the system to get going instead of just giving it to them. So, yeah, we love bitters in naturopathic medicine.

Dr. Weitz:                         Cool.

Dr. Greenberg:                 So, I was talking about the beta-glucuronidase. Just in case you guys do stool tests and wonder what this is, beta-glucuronidase, it tells us ASE. It’s an enzyme, and just a little biochem lesson, it has to do with the liver. So, the liver in phase two detoxification, phase one is how do we change the molecule into something and then phase two is how do we get it out of the body. So, one way that the liver can make a substance water-soluble is to do something called glucuronidation. It takes the glucuronic acid and sticks it on the molecule.   Estrogens are taken out of the body this way through glucuronidation as are some toxins.  So, the liver puts this glucuronic acid on, and now it can be put into the poop, and you poop it out, and we get rid of that excess estrogen and the excess toxins.  Well, this enzymes, beta-glucuronidase, can be produced in high amounts by a bacteria and it does something not good.  So, now we’ve got the substance the body was trying to get rid of, estrogen or toxins, the liver has put a glucuronic acid on it.  Well, at the last minute, beta-glucuronidase comes in and goes, “Hiya!”  It releases that glucuronic acid.  Now, this substance is like, “I’m free,” and it goes back into circulation in the body.  So, if you have estrogen-dominant females and they have high beta-glucuronidase, this might be why they’re estrogen-dominant. They’re not getting the estrogen out, but it can also impact other toxins and things the body is trying to get out.  Normally, you treat down the overgrowth and it will rectify this, but there is a supplement called calcium D-glucarate that you can give to block the beta-glucuronidase. She’s breastfeeding, so she’s not going to get the calcium D-glucarate, but if she wasn’t, I might give it to her, and that’s a pretty classic supplement that we give in naturopathic medicine. It’s a symptomatic treatment, but to deal with the high beta-glucuronidase while we treat down the gut.  Then her last thing, her secretory IgA is really, really low. Again, leaky gut, no akkermansia, low secretory IgA. She’s got leaky gut, and so we’ll have to deal with that.

                                                On her OAT test, we see that her aspergillus is not an issue. This is all nice and low, but she has candida overgrowth as I would expect with eczema. So, we have to treat the candida. The fusarium is undeterminate. It’s elevated, but it’s not frank high. So, I’ll think about whether or not she needs a mycotoxin test.  We talked about candida and oxalates. So, hers are elevated. She’s not high yet, but she’s going that direction. Again, this is due to the candida throwing off oxalates. Her vitamin B2 actually was not deficient because she’s still on prenatal vitamins. So, she’s getting a whole pop of B2 and it’s helping her, but I think if she wasn’t on the prenatal vitamins, she would be deficient in this vitamin B2 as we talked about.

                                                So, for her, I have to treat the staph infection on her skin. She’s bleeding and oozing. She cannot sleep at night. I am okay with topical antibiotics. Mupirocin ointment for a few days is a really good way to quickly get a staph infection down, and it’s a topical. It’s not an oral, but then I created an antibacterial essential oil salve for her to use. So, we just used the mupirocin for a few days, but it does a pretty good job of whacking it down, and then we’re going to work on all the underlying factors.    For her H. pylori, I have to give her altered protocol because she’s breastfeeding. So, she didn’t get my normal H. pylori, but there’s a different protocol, of course, safer for baby. It’s mastic gum and all this stuff that I think most of us treat H. pylori with. Her low elastase, this is where I give her that and the H. Pylori, the digestive enzymes, the hydrochloric acid, and the bile supplement.

Dr. Weitz:                         Which is your favorite digestive enzymes?

Dr. Greenberg:                 I really like DuoZyme by Karuna. They have all three of these. Integrative Therapeutics actually has a very good one, too, Panplex Phase 2, and I use that one a lot as well. So, those are my two favorites because it’s hard to find the digestive enzymes, the hydrochloric acid, and the bile together. So, one of those two.   For the bacterial overgrowth, again, I’m going to treat with herbs, but a modified protocol, safe for breastfeeding mom knowing her infant is going to get exposure to these herbs, and same with the candida. She doesn’t have akkermansia, so I’m going to give her the probiotics with akkermansia, the Pendulum, and give her the IgA supplement while I’m treating all these dysbiosis.

                                                Again, I would have given her calcium D-glucarate for this high normal beta-glucuronidase, but she’s breastfeeding and this has not been proven safe for breastfeeding, so she did not get it. Then, of course, addressing the skin barrier disruption with topical protocols to support.

                                                This was Alice on her first visit. Three weeks later, we can see it’s actually in a better state. This is really common for staph infections. They start off really concentrated, and thick like that, and oozing, and crusting, and bleeding, and creating all sorts of havoc, and as we start to treat it, it does spread out, and I think this is just partially as they’re putting the topicals. It’s spreading it around a bit, but it’s okay. You can see that. It’s a much better state actually than where it was and she’s not being tortured at this point.   Then a few weeks later, it’s gone. You can see that the skin is still not completely normal because it’s been traumatized like this for nine months. It’s going to take some time for the skin to repair itself, but there’s no more eczema. There’s no more staph infection. She’s completely normal. Then, actually, the baby had eczema. So, once we cleaned her up. I started treating the baby for eczema.

Dr. Weitz:                         What are your favorite candida formulas for adults and infants?

Dr. Greenberg:                 Well, so for infants, it’s different. For infants, I really like Biocidin Liquid. It’s broad spectrum, and it addresses a lot of things, clostridia, candida, bacteria, and it’s safe for most infants. It just have walnut hull and leaf, so make sure that there’s not a walnut problem in any patient. There’s also formulas by another … Obviously, infants cannot swallow capsules. Infants, we’re not going to give alcohol. So, I give them glycerides, and Biocidin is a glyceride.  There’s also a company, Beyond Balance, that makes glyceride formulas. So, I use some of their formulas in infants as well to treat the dysbiosis because, again, it’s not alcohol-based, and it’s proven safe for infants, and we can get it down easily.    For adults, I use a lot of different things. I actually like Candida Support now. I like grapefruit seed extract, caprylic acid, neem. It just depends. I do different protocols for different people, and it depends on the full spectrum of what I see as well, but those are some of my favorite internal candida protocols.

Dr. Weitz:                            Somebody asked about Saccharomyces boulardii to increase sigA.

Dr. Greenberg:                 Yeah. I know a lot of people use sac boulardii. The problem is it’s a yeast, and I would say most of my patients have candida overgrowth, and I just don’t like to give more yeast when yeast is a problem. So, I know a lot of people do sac B. I just don’t really use it because almost all of my patients have candida overgrowth, and I just don’t want to be plowing them with more yeasts. So, I think it works for some practitioners. I just personally don’t use it.

                                                So, you guys just saw two case examples on eczema, and you may be thinking, “Well, that’s great, but does it work for other dermatological disease?” I’ll just show you some quick before and after photos. So, this was an acne patient, 20-year-old, complaining of back and chest acne. Test, treat the gut. One month later, pretty significant improvement in the acne, and this was the chest. Same patient.

                                                This is a patient with actually fungal acne. So, we see those little white spots. That’s malassezia yeast in there. It’s different than acne vulgaris, which is bacterial. This is in the first visit, and in three months, we can see clear skin.

                                                This was another patient with classic acne vulgaris on the cheeks, another teenage female. Two months later, we see it’s clear and the other cheek.

                                                This is a patient who’s an adult who came to me with a full body rash. A lot of her body looked like this. It was pretty brutal. She thought it was, again, she was really focused on food, and it’s a food reaction and a food allergy and I had to be like, “We’re leaving this food discussion behind. It’s not food. It’s pathogens.” Test and treat the gut. Two months later, gone, done, cleared up. That was her arm. This was her stomach.

Dr. Weitz:                            What kind of rash is this?

Dr. Greenberg:                 This, she had a lot of candida. I mean, again, it was a lot of different types of dysbiosis, but there was a big fungal element to this one. Candida will just wreak havoc on your gut and havoc on the skin. Clean up the gut, you’re going to clean up the skin. Of course, I had a whole topical protocol for her as well, but it was pretty uncomfortable.

                                                This is a rare condition called palmoplantar pustulosis. It’s in the family of what we call papulosquamous disorders, so psoriasis. It’s also called pustular psoriasis. Although the interesting thing about it is these pustules are sterile. So, if you sample them, there’s not going to be anything in there, and it’s really considered a mysterious disease. We don’t know why it’s happening. This patient, her dermatologist was trying to put her on Otezla. She’s a medical professional, needs to use her hands. It was a huge problem. So, at the first visit, five months later, she’s got a big improvement. She’s able to use her hands for her job.    Two months after that, we’re starting to see some good clearance, and then one and a half months later. So, these kind of autoimmune diseases take much longer to treat than a simple eczema, but this is considered an untreatable disease, and you can see from the first visit to now huge, huge difference, almost normal, and the dermatologist say it’s untreatable mostly. You have to go on biologics for it.

                                                This is another patient with a psoriatic type disorder. If you look down at his ankles, you’ll see red, oozing, crusting, bleeding. I said oozing, I hope you all are already thinking that’s a staph infection or an infection. You’d be right. We get these staph infections on top of other skin diseases, even psoriasis. So, he’s been living like this for two years. You can see it’s going up his legs. He’s not able to wear shoes and socks. Total disaster for him. He’s not able to participate in his family.   Seven months after treating him, he’s totally cleared up from this and also, he’d seen many dermatologists over the two years and nobody could help him. This was the front at month zero and seven months later. His feet are also clear. He just took it in the shoes.

                                                This is an infant with alopecia areata. You lose hair. It’s not just from the scalp. You can lose your eyebrows, your eyelashes or full body hair. This infant actually lost all his eyelashes and we were able to treat the gut and have them come back. This is a progression of it. It was also on his head, but I just got the eyelash pictures in here.  So, does this method work for other dermatological disease? It does. It really does.

                                                Some things that you may want to consider as a practitioner using these methods. You’re going to have to analyze all of the problems that you’ll need to address on both labs. So, I look at everything as these are all my problems, and then I have to decide what order I want to treat them in. You can’t treat everything all at once. There’s going to be probably too many issues to address.

                                                I pretty much start with mold and candida and/or H. pylori because the H. pylori is upstream in the stomach, but it does depend on what I’m seeing and what the symptoms are.

                                                You want to learn the best protocols to treat each issue, both topical and internal. Then, of course, you’re going to adjust your protocols based on your patient, infant, toddler, breastfeeding mom, what allergies do they have. I move through different protocols every one to three months depending on the patient and how things are going.   So, there is no one protocol. Everyone’s like, “What’s the eczema protocol?” I don’t have an eczema protocol. It changes and it’s different for every patient. This really is individualized medicine, and that’s how you get good results for people.

Dr. Weitz:                            Have you ever treated lichen sclerosus?

Dr. Greenberg:                 I haven’t. I have a new patient who I think I’m going to be seeing soon. I’m planning on treating it the same way. It’s an autoimmune attack. Depending on how far the scarring is, it’s very hard to bring back skin that is already sclerosed. I think the goal would be to reduce the further sclerosus. I haven’t treated it, but I certainly plan on applying the same methods to it.

                                                So, if you’re wondering like, “Well, how can I learn how to analyze stool test and OATs and mycotoxin test?” The labs who you can run these with, they usually have a lot of free educational videos available, and you’re going to need to invest a significant time doing it. Some of the labs has been on weekend training courses. I think it’s vital for the OAT. It’s so complicated. When you first look at it, it’s like, “What is happening on this test? I don’t understand this. How could I ever understand it?” Do the weekend training course if you want to understand OATs.  There’s paid courses offered by a lot of functional medicine and naturopathic doctors and professionals. I think they’re a couple of thousand dollars. I’ve never taken them, so I can’t say whether or not they’re worth it, but I think you can do it on your own if you can put in the time.

                                                The labs offer free consults on each lab that you run. I would suggest that you take those free consults at least on the first 20 tests that you run that’s a new test for you. You’d schedule a half hour visit, and that professional at the lab is going to take you through it and help you understand what are you looking at, how do you put these pieces together. It’s really useful.   I always say start by running the test on yourself first. Be your own guinea pig. Schedule a consult and see what’s going on in your own gut and try to treat yourself. Then you can start using it on patients.

                                                How do you learn to use herbs? I really think people need formal education and training. I know it’s not like pharmaceuticals where you need to be licensed. Anyone can prescribe herbs, but I think you really need, in order to be responsible, to get formal training, and not just an online course.      There are a lot of courses and ways to become trained as a registered herbalist or a lot of professional degrees with herbs built in like naturopathic doctor. We have four years of herbal training and it’s part of our board exams to pass an herbal medicine section. Otherwise, you won’t be a licensed naturopath. Same for traditional Chinese medicine in Ayurvedic doctors. The herbs are built in and they’re tested and formally trained on it.

                                                In terms of getting mold and mycotoxin literate, I also think you should get some formal education and training. This one can be online. There’s a lot of doctors who offer courses on it. Like there’s SIBO training courses, there’s mold and mycotoxin training courses as well, but they’re going to assume that you either have formal herbal or pharmaceutical training because, again, this is mold. So, you’re going to be treating it with prescription antifungals or herbal antifungals, and you need to know what you’re doing and have proper licensing.

                                                If you guys like skin and find it interesting, I am the Program Chair of the Naturopathic and Integrative Dermatology Series on LearnSkin. This is free. There are 20 courses. They’re CE accredited. So, you can earn up to 10 free credits, either AMA PRA Category 1 if you’re an MD. There’s naturopathic credits if you’re an ND and CBRN for nursing. It’s a lot of the stuff that I talked about. So, there’s naturopathic approach to atopic dermatitis, gut dysbiosis and its role on skin disease. So, you can check out. There’s SIBO testing for dermatological disease conditions. You can head on over the LearnSkin and take any of these courses. Again, they’re totally free.  This is my contact information. I’m at the Center for Integrative Dermatology. If you want to contact me, it’s drgreenberg@integrativedermatologycenter.com. Yeah. That’s it. Well, we’re at 8:00, but I can stay and take questions if people are interested.

Dr. Weitz:                         A couple more questions. Somebody asked about seborrheic keratoses.

Dr. Greenberg:                 Seborrheic keratoses and not dermatitis? So, seb keratoses is, yeah, it’s a disease of keratinocytes, and it can look pretty fungi on the skin. They can be removed. They are never going to turn into anything carcinogenic as opposed to actinic keratoses. AK, actinic keratoses can and will turn into basal cell carcinoma or squamous cell carcinoma. Those are the non-melanoma skin cancers, but seborrheic keratoses is never going to turn into a malignancy. It’s just unsightly, and a lot of people, it can be genetic, it can be due to sun exposure, but it’s nothing to be concerned about medically, but you can have them removed. They’ll burn them off or cut them off. Yeah, but they can never turn into something carcinogenic.

Dr. Weitz:                         Somebody asked, “Which mycotoxin course do you recommend?”

Dr. Greenberg:                 So, Dr. Shoemaker is probably the most famous protocol. I, personally, Dr. Jill Crista is a naturopathic doctor. So, I did Jill Crista’s course for mold and mycotoxin certification. I really enjoyed her course, and find it very usable. I also just signed up. I think it’s AAEM, just had a mold and mycotoxin course that I’m still working through, but I found it helpful. I like both of them because … So, Dr. Jill Crista is a naturopathic doctor, so she does talk about some prescription pharmaceuticals, but she’s a lot heavier on the supplement and herbal treatments.   The AAEM course that I’m doing right now is MDs. So, they’re pretty heavy on the pharmaceutical stuff, but I like learning about both and getting both perspectives. So, even do more than one, but I can personally recommend Dr. Jill Crista, C-R-I-S-T-A.

Dr. Weitz:                         Somebody asked, “What stool test do you recommend?” I know you like to use the GI map, right?

Dr. Greenberg:                 Yup, and I know that they’ve been on here. I really love the GI map. I find it price-wise is great for patients. I love that it includes H. pylori. I find it really easy to read, very usable and actionable. When I treat on the basis of my results, I usually get very good results for my patients. I’m doing, if any of you guys are members of IFM, the Institute for Functional Medicine, they have an upcoming conference. There’ll be an international conference in June, and I was selected to present a poster, and I’m presenting the OAT and stool test for about 35 acne patients showing what dysbiosis I see in acne patients. So, if any of you guys are at that conference, you could check it out, but it’s based on 35 GI maps and 35 great plain OATs. Those are the two tests that I used.

Dr. Weitz:                         Let’s do one more question. Can you answer, how do you treat hair loss, in 30 seconds or less?

Dr. Greenberg:                 Well, it depends. There’s two types of hair loss. There’s alopecia areata, which is an autoimmune problem, where you’re attacking the hair follicle and there’s androgenic alopecia. It is very complicated. If any of you guys are interested, through the CNDA or California Naturopathic Doctors Association, I’m going to be doing a two and a half hour presentation webinar on hair loss through the CNDA in August. So, there’s no 30-second description for hair loss. It’s pretty complicated, but if you want to attend the two and a half hour webinar, go over to the CDNA and the California Naturopathic Association, and I’ll be giving that webinar in August.

Dr. Weitz:                         That’s great. If you could post that on the Facebook page also, that would probably be helpful. Thank you so much, Dr. Greenberg. So many of the practitioners said it was an amazing presentation, which it was. So, thank you so much.

Dr. Greenberg:                 Thank you all for your time. I really appreciate you spending Thursday evening with me.

Dr. Weitz:                         Thank you. Bye, everybody. See you next time.


                                                Thank you listeners for making it all the way through this episode of The Rational Wellness Podcast. Please take a few minutes and go to Apple Podcast and give us a five-star ratings and review. That would really help us so more people can find us in their listing of health podcasts.

                                                I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111, and take one of the few openings we have now for a individual consultation for nutrition with Dr. Ben Weitz. Thank you and see you next week.


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