173: Malassezia: The Bug Behind Many Fungal Skin Problems w/ Dr. Julie Greenberg

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Ever heard of malassezia? No? You're not alone! This organism is not very well known, but it is actually a huge contributing factor toward skin conditions like eczema, psoriasis, tinea versicolor, and certain types of acne.

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My guest today, Dr. Julie Greenberg, is a licensed ND who specializes in integrative dermatology.

She is the founder of the Center for Integrative Dermatology, a holistic dermatology clinic that approaches skin problems by finding and treating the root cause.

Dr. Greenberg hold degrees from Northwestern University, Stanford University and Bastyr University, and received advanced clinical training at the Dermatology Clinic at the University of Washington Medical School and at the Pediatric Dermatology Center at Seattle Children’s Hospital.

She is also the Program Chair of the Naturopathic & Integrative Dermatology series on LearnSkin.com, a learning platform for integrative health care professionals.

Join us as we talk about malassezia, a bug that is responsible for several fungal skin problems.

Has malassezia been found to be the cause of your skin rash? Let me know in the comments!

In this episode:

• What is malassezia?
• What's the relationship between malassezia and seborrheic dermatitis (dandruff)?
• Why is the skin pH important? What happens when the pH of the skin is too high?
• Is there a test to look for malassezia?
• What other skin conditions are linked to malassezia?
• Are there any topical or dietary solutions for malassezia?
• Why you should not apply undiluted essential oils directly to the skin.

Quotes

“Over 50% of adults will have some form of dandruff in their life. That's usually a non-inflammatory form of seborrheic dermatitis.” [2:42]

“Our skin, many people are surprised to learn, is also supposed to be relatively acidic, like four, 4.5 to five, 5.5, and when the skin becomes more alkaline, or has a higher pH, it cannot defend itself as well, and we do get problems.” [5:04]

Links

Find Dr. Greenberg online

Healthy Skin Show ep. 107: Symptoms Of A Staph Infection On Your Skin

Healthy Skin Show ep. 149: How Staph Aureus Wrecks Your Skin w/ Dr. Julie Greenberg

Gut Dysbiosis and Its Role in Skin Disease: A LearnSkin course I co-authored

LearnSkin Naturopathic and Integrative Dermatology Series

173: Malassezia: The Bug Behind Many Fungal Skin Problems w/ Dr. Julie Greenberg FULL TRANSCRIPT

Jennifer: Thank you so much for coming back on the show, Dr. Greenberg. I really appreciate you joining me again.

Dr. Greenberg: You're so welcome, Jen. You know I love the show, and I subscribe, and I get excited every time there's a new episode. I'm always happy to be here.

Jennifer: One of the things that was funny when we were talking the last time, because for those of you who remember, Dr. Greenberg talked all about staph, and we can share that episode in the show notes, we were talking about malassezia, which is kind of a different, I don't want to call it a beast, but-

Dr. Greenberg: It is a beast.

Jennifer: It is a beast.

Dr. Greenberg: It's a yeasty beasty.

Jennifer: We were like, “We need to talk about this.” For those people who are unfamiliar with what malassezia is, let's start there. What is this organism?

Dr. Greenberg: Yeah. So, I've got bad news for you and everyone, you've got malassezia, it's everywhere. It is a lipophilic yeast, that means it eats lipids, and it's a normal part of our human body, our microflora. There are 14 different species of malassezia on humans, but actually, we know they're on dogs and elephants, and we actually think that probably every mammal has malassezia, and malassezia really evolved to be on mammalian skin. We've all got it, although most people haven't heard of it. I think it sounds a little like an alien, like, “We are from the Planet Malassezia.”

Dr. Greenberg: Yeah, it's just a yeast that we've all got. I don't know why it's not talked about more in dermatology or why we don't know about it, but anyone who's had dandruff, then you have been affected by malassezia.

Jennifer: My husband had dandruff and that was really my introduction to this lovely organism. It's something where he had used Head and Shoulders for a long time, and we have a lot of listeners that have dandruff, or AKA seborrheic dermatitis, and they really struggle with it, not just on the scalp, but around the ear area, on their face. What are your thoughts about malassezia in regards to seborrheic dermatitis?

Dr. Greenberg: Malassezia causes a lot of different skin conditions, but the most common is, as you said, seborrheic dermatitis, and we call it Seb Derm. Seb Derm can be two-fold. You can have Seb Derm of the scalp, which in adults is dandruff. Over 50% of adults will have some form of dandruff in their life. That's usually a non-inflammatory form of seborrheic dermatitis. Babies get it, and we call it cradle cap. Then, as you said, it can be on the face or body, and so it doesn't necessarily need to be on the scalp.

Dr. Greenberg: On the face, it tends to occur in areas that are rich in sebum. Sebum is one of the lipids that's produced on our face, and of course the malassezia wants to eat that. It's its own buffet on your face. It will occur in certain places that are rich in sebum, so around the eyebrows, the glabella, which is the smooth area of skin between your eyebrows, the nasal labial fold, those are the areas of running down the nose on both sides, the anterior hairline. Then I see it a lot, particularly, there's something about the 40-something female crew, they get it around their eyes and it's kind of like, they look like raccoons, but with redness all around their eyes. A lot of times, Seb Derm of the face gets misdiagnosed as eczema. I can't tell you the number of patients I have who come to me and they say, “I have eczema on my face.” I look at them, or I see pictures of, for telehealth visit before they come, and I think, “No, you don't have eczema. You have Seb Derm of the face.” It's a totally different beast.

Jennifer: We were talking the last time, when we were discussing staph, in how there can be this weird connection with staph and the eyes, and having staph hiding in your nostrils. I'm just asking this question, people who have these specific patches of Seb Derm, are there any connections or things that you look for that help sort out how to start getting it under control?

Dr. Greenberg: Yeah, with all of the skin stuff, so whether it's staph or Seb Derm, or even herpes, I think we talked about skin pH on the last podcast, and we're going to talk about it again. Our body has evolved to operate in different places at different pHs. Our stomach is very acidic, a very low pH, and our skin, many people are surprised to learn, is also supposed to be relatively acidic, like four, 4.5 to five, 5.5, and when the skin becomes more alkaline, or has a higher pH, it cannot defend itself as well, and we do get problems. That's where we'll start to see problems with like malassezia or with staph aureus.

Dr. Greenberg: I already know, when I'm looking at somebody, whether they've got a Seb Derm problem, and it's malassezia, or a staph infection. I know that their skin pH is off, and the skin barrier is compromised, and so we have to do a lot of that fundamental work to fix it. Seb Derm is different. Malassezia is a yeast or fungus, staph aureus is a bacteria. So yes, I'm absolutely looking at the underlying kind of root cause of the skin pH being too high, but I'm addressing it with different herbs and different protocols because one is a fungus, and one is a bacteria.

Jennifer: So you look at photos and you can kind of tell, if someone's going to their doctor, and say they do have that raccoon situation around the eyes, would you recommend that they request a culture? What's the best way for… Is there a test to look for malassezia?

Dr. Greenberg: For me, it's really more of a clinical, I don't really need to go do testing because, like I said, it's going to be in the sebum-rich areas. I'm going to look at them and see, that is a very classic Seb Derm presentation. You can certainly get co-infections, so you could have malassezia and staph at the same time. You could culture and see what's there, and malassezia's infection is really on the surface. You could do a scraping, and you could put KOH on it and look it on under a microscope, or sometimes they'll do a surface biopsy. But, I really think it's overkill, I think we know pretty quickly. If you're used to seeing Seb Derm, you can look at it and see, and also you can just try, I just do like what I call presumptive protocols, “Let's just try this for a few days,” and usually, you're going to see a big response to it.

Jennifer: Let's go through a few other conditions, and then we can talk about maybe some of the things that, some herbs or something, that people could consider do's and don'ts, that kind of thing. Tinea versicolor is another one, it's less known, but it does happen. I've worked with a number of clients who've had this.

Dr. Greenberg: Yes. Tinea versicolor, and it used to be called pityrosporum versicolor, because malassezia used to be called pityrosporum, but now it's more classically known as tinea versicolor. A lot of times you'll see this on the trunk. A lot of people think like, “Oh, maybe I got a sunburn and then I peeled, and I've kind of got these white spots.” But when you have that year-round, that is much more likely tinea versicolor. We call them hypo- pigmented, scaly spots. A lot of times it's going to be on the upper trunk, so the chest and back, maybe the upper arms.

Dr. Greenberg: Again, it just looks like these whitish spots, scaly spots, but then a lot of times it can also look kind of reddish. It's interesting, that's kind of the hyper-pigmentation. Some people will have whiter spots on their arm and chest, and then these redder spots on their back, and they don't realize it's the same thing. It's the malassezia, and it's tinea versicolor. It's just a superficial, fungal infection that's infected the skin. It's actually really common, a lot of people just aren't really sure that it's actually a thing, so they won't even go to their doctor about it. A lot of times it won't go away on their own and they notice it a lot more in the summer because they're out, and especially guys, their chest and back are exposed to the sun and they'll get tan, and then they'll say, “But there's these spots that just don't tan,” and that's where the malassezia is infested.

Jennifer: Then we've got a fungal acne, as well.

Dr. Greenberg: Yeah, there's pityrosporum folliculitis, which a lot of times will get confused as acne. If you're treating acne, and there's these kind of tiny little, we call them monomorphic papules and pustules, especially like on the forehead. Or if you can tell that it's a folliculitis, so a folliculitis is an infection of the hair follicle. You can certainly have bacteria, and you can have a staph folliculitis, but a lot of times if you're treating that and you're going at it from a bacterial perspective, and the folliculitis or the acne isn't getting any better, it's worth exploring if it's actually fungal in origin, if it's actually malassezia that's infested the follicles.

Dr. Greenberg: It is, I guess, a form of acne, but it's not acne as we think of it. It's a fungal acne, or a fungal folliculitis. And that, certainly if you're on antibiotics, that's not going to respond to it. Herbs are at least a better approach in terms of if you're not sure what it is because herbs are broad-spectrum usually, which means that a lot of times they're going to fight bacteria and fungus because the plants can't run away, they can't punch at bacteria or fungus. They make products to defend themselves and it's kind of always at the ready, and so they're what we call much more broad spectrum. They're usually antifungal and antibacterial to some extent.

Jennifer: I thought it was really interesting, too, I also work with a lot of clients that both have psoriasis and eczema, and it is not uncommon to see yeast show up in some of their testing. Talk a little bit about how these two conditions, these two really big conditions, like you can have a malassezia component to this.

Dr. Greenberg: Yes, and it can be a huge problem. In fact, it can be mistaken. Like I said, a lot of women come in, they think it's eczema, and it's not. Then, I just had a patient for 24 years she's been diagnosed with scalp psoriasis, and I took one look at her, and she's had also 50% hair loss on her scalp because the scalp is so traumatized that it's affected the hair follicles. Her hair is at least 50% less, I mean, just huge gaps of hair thinning all over. I took one look at her, and it's not scalp psoriasis. It is a terrible, terrible scalp infestation of malassezia, and seborrheic dermatitis. It can get misdiagnosed and mistaken, but you can definitely also have psoriasis and/or eczema, and then get an overlay of seborrheic dermatitis, and that's twofold.

Dr. Greenberg: In psoriasis and eczema, we already know that the skin is compromised. The pH of the skin is always going to be higher, and now you've actually got a compromise in the skin, so it's much easier for co-infections, whether it's staph or malassezia. It's a little tricky with the scalp psoriasis, because you can definitely have scalp psoriasis and then also have a malassezia infestation on top of it. You do want to treat that because you're going to improve the scalp either way, even if you've got scalp psoriasis, if you've got malassezia on top of it, you're going to do a lot of good things for the scalp by specifically treating the malassezia. And same for the eczema, it's so irritating to the skin, but those co-infections exist a lot, and need to be treated separately.

Jennifer: Then we've got the pityroiasis alba.

Dr. Greenberg: Yeah, so pityroiasis alba, we don't know exactly what the root cause of pityroiasis alba is, but we do think that malassezia yeast play a role, and the same reason in terms of the tinea versicolor. Pityroiasis alba is usually on the face, and you usually get these hypo-pigmented white spots. It kind of looks like a tinea versicolor, but it's just on the face. Pityroiasis alba in skin of color, it's actually much easier to see, because you can see the hypo-pigmentation. The malassezia yeast produces a metabolite pityriacitrin, and it inhibits an enzyme called tyrosinase, and that caused the hypo-pigmentation. The malassezia is all over the body, particularly on the scalp and face, but it really manifests when it gets overgrown in lots of these different ways. It's really a huge pathogen for people and derm conditions, but it doesn't get that much research and it doesn't get that much attention, I think because it's definitely not life-threatening.

Jennifer: But it can be life-wrecking though.

Dr. Greenberg: Yes.

Jennifer: I think that's an important point to make, because I have talked to people who are performers. There was one gentleman that contacted me, I don't know if he was a cellist or whatever in an orchestra, and he's like, “I can't wear a black tuxedo because of how bad this is.” Or people who have such severe, it almost looks like, I know with my husband, when it would get really bad, his skin and around his scalp in the front looked like he was on fire. It was so irritated.

Jennifer: I think that's an important distinction, and I love that you're there to help support people through this, is that, conventionally, it's just like, here's a topical, here's this. Although I have had one dermatologist that was willing to give a client who ended up with tinea versicolor, I think she gave her nystatin, or some other anti-fungal, Diflucan or something like that, which also did help. But as far as how this happens, I mean, obviously a disturbance of the skin pH, but do you have any other thoughts about what would allow a normal commensal organism on the skin to get so out of control?

Dr. Greenberg: To your point, my patient has suffered, lost half her hair. Her scalp is, what you're saying, all over the scalp. It's absolutely life impacting for people, and it needs to be dealt with. The causes of malassezia infestation is something we're still trying to figure out. Usually there is some sort of overgrowth of malassezia that needs to be treated. It seems to be less an overproduction of sebum, so it's not so much that these people are producing so much sebum that it's causing a malassezia overgrowth, but we know there's functional changes on the skin. Again, the higher pH of the scalp and skin allows, malassezia wants the higher pH, so that allows it to thrive, but we see real changes in the scalp and skin of people who get malassezia infections.

Dr. Greenberg: There's changes in lipid metabolism, there's changes in the composition of the fats on their skin and scalp. We're not sure why that happens. There's changes in the amino acid profile, there can be changes in vitamin metabolism on the skin, changes in the microbiome. Interestingly, especially in our atopic dermatitis patients, there's an actual immune response that goes on. Anywhere from, they've had stats of 20 to 80% of people with eczema, with atopic dermatitis, have an IgE immune response. Part of what's happening is, malassezia feeds on our sebum, so that's part of what causes the dry flaky skin, and it's both the scalp and the face, because they're eating the sebum, and the sebum is what moisturizes the skin. But it's not just that they've eaten up your sebum, it's that the malassezia is kind of a byproduct. It can process saturated fatty acids, but not unsaturated fatty acids.

Dr. Greenberg: Now the unsaturated fatty acids produced as a byproduct, sit on top of the skin, and for some reason, people who have dandruff, or Seb Derm, or all of these problems, the reason why it looks red and inflamed is they're having an actual immune response to these byproducts. We're not sure exactly why. One of the biggest things that gets left behind is an unsaturated fatty acid called oleic acid. A lot of people have sensitivity to oleic acid, as many as 50% of the population. We're not sure why.

Dr. Greenberg: Oleic acid is actually one of the major constituents of olive oil. It's why I do not like olive oil at all as a base of any of my skin products. Certainly, if you've got a dandruff or a Seb Derm problem, you should not be using olive oil on your skin full stop. 50% of the population has a sensitivity to oleic acid that I don't use it as a carrier oil for any of the skin products that I use, and I don't know why it gets used so much in skin products, but some manufacturers are starting to swap that out for other carrier oils, like a sunflower seed or a grape seed oil, things like that.

Dr. Greenberg: But yeah, there's an actual immune response that's going on, and interestingly, people who are immunosuppressed, so people who have had organ transplants who are on immunosuppressive medications, or who have HIV, they get very high rates of seborrheic dermatitis, like up to 83% of them will be affected. We're not exactly sure what's going on, but cytokines, so the inflammatory chemicals that cause inflammation, those are increased and there's a legit immune response going on in people who have these problems.

Jennifer: So for people who have these issues, are there any particular herbs or botanicals? I love that you shared the whole like, “Hey, olive oil is not going to be a good thing for you.” Are there some things that people could potentially try, other than Head and Shoulders, that may be beneficial? I've heard things like, “Do an apple cider vinegar rinse,” but most people who I've heard back from who have read that online said that it didn't help. So, thoughts on what you find might be, at least from a topical perspective, might be helpful, or if there's any diet shifts you think are supportive of this?

Dr. Greenberg: Definitely. I'll take the topical aspect first. For me, I use protocols, that's, I think, part of naturopathic medicine or functional medicine, that differs a little from conventional medicine. Conventional medicine, sometimes they're going to hand you a tube or one thing and say, do this one thing. For us, it's more of a protocol.

Dr. Greenberg: Seb Derm is one of those things, there's certain conditions we get where it's like, “Oh, I know I can treat this,” and other ones where it's like, “Yeah, this is going to be a little tougher.” When I get Seb Derm, it's like, “Yep, we got this.” It's a little bit multifactorial, there's good research on lots of different essential oils that impact lots of different strains of malassezia. Myrtle is one of them, there's a lot of research on it. For me, I love rosemary. It's a great antifungal and antibacterial, but it's a really good antifungal.

Dr. Greenberg: For my patients, it starts in the shower. Neem is another great herb, there's shampoos and conditioners with neem in it. We start there. We'll add Rosemary essential oil, in appropriate amounts, to the shampoo and conditioner, and even apple cider vinegar rinses in the shower. Now, the thing to keep in mind is anything you're using in the shower, I tell them, “Leave it on for two minutes before you wash it out,” but it's only staying on your scalp, or your face, for a couple minutes when you're in the shower. So that can't be the end of the story because it doesn't have enough time to do its work. So when they get out of the shower, there are things that I want them to apply.

Dr. Greenberg: Apple cider vinegar is actually a good one. The problem is you're going to smell like vinegar, and especially when people exercise, then they start sweating vinegar from their scalp. I think hydrosols are a better option because they smell lovely, so of course, I love rosemary hydrosol.

Dr. Greenberg: There's lots of ways to approach it, and at first, you have to do much more aggressive protocols daily. And then eventually, once we've got the malassezia under control, then we kind of ratchet it down and find more of a maintenance level for either the face or the scalp. Usually we can keep it away.

Dr. Greenberg: Sunshine is another one. Dandruff and Seb Derm tends to get a lot worse in the winter. We're not sure why, if the sun actually kills it or does something else, but sun exposure usually helps to decrease the infestations as well. Then things like aloe, on the skin, to lower the skin pH, which the apple cider vinegar and the hydrosols do. You have to be a little bit careful with the oils because you don't want to feed the malassezia, the saturated. Just coconut oil, I don't recommend, but coconut oil infused with something like neem, or infused with something like rosemary, changes it and does make it antifungal. I don't recommend people to start putting a lot of oil because you can end up just feeding the malassezia.

Jennifer: And Dr. Greenberg, I just want to also just question real quick, because I don't want someone to think they should go out and buy a rosemary essential oil for example, and just put that straight on their skin, right? We're we're always diluting that? Is that correct?

Dr. Greenberg: That is an excellent point, yes. Never, never put essential oils directly on your skin, which is neat. You don't want to do that. That is harmful to the skin. These are very powerful, concentrated substances, and you should be under the guidance of someone who's experienced with using essential oils, so a naturopathic doctor, a registered herbalist, somebody who's trained in it. You always want to dilute it, and carrier oils, and you need to know the correct dilution. Each essential oil has a different concentration that can be used on the skin, or a dermal limit. You have to know, not only how to calculate the concentration, but with the particular essential oil that you're using, what's the dermal limit, and now if you're creating a combination of essential oils, what would be the total dermal limit that you would want?

Dr. Greenberg: I do not recommend that people do this on their own, it needs to be under the guidance of a professional, or you can do a lot of damage. Certain essential oils, like bergamot, are phototoxic, so if you put them on and then go in the sun, you can suffer a very extreme third-degree burn of the skin that can leave you scarred for a lifetime. It's not something to just play around on your own with.

Jennifer: I like to be very clear about that because I never want someone to go and start going, “Oh, essential oils, great, I have a bottle of my cabinet, let me just put it on my skin,” and then we've got problems. Thank you for clearing that up. Since we're getting close to the end, I want to make sure to talk about some… And are there any dietary suggestions that you usually make? Because I think the important thing to also share with people here is this is not just an outside job, right? That's typically how it's addressed in conventional methods, right? Shampoos, that's pretty much all you're given for the most part. There is definitely an internal component, it's not just external. What are some things you might recommend to your patients who are struggling with overgrowth of malassezia?

Dr. Greenberg: First, obviously, I'm going to look at the whole person. I always tell my patients, we kind of have weaknesses in our system. Some people tend to get bacterial infections, some people tend to get viral infections, so maybe herpes or molluscum, warts, and then some people kind of get fungal infections. I look around their whole body, do they also have candida? Do they have toenail fungus? Is there a fungal profile going on?

Dr. Greenberg: I do see, a lot of times, that for some reason, my patients who have Seb Derm problems, they will have candida colonization. We're not sure exactly what it is, but there seems to be a cross-reaction of immune response between the body producing antibodies in a response to candida in the gut, and then Seb Derm on the skin. We still don't know the exact correlation, but hopefully in the future, research will help elucidate, more than just the fact that they are in the yeast and fungal family, exactly what's happening. I look and try to see if there's a candida colonization.

Dr. Greenberg: In babies with eczema, I often see candida along with the Seb Derm, the cradle cap. That's very, very common. I see that together all the time in babies. Then the third component I see is that they have a milk sensitivity, and not human, but cow or goat milk, and adults as well. Anybody who's dealing with Seb Derm, I ask them to cut out dairy, at least while we're treating it, and to see if it makes a difference. Again, we're not sure what that connection exactly is, but there is one clinically that I see all the time. A baby obviously is going to have a tougher time cutting out dairy if they're on a formula, but there are several dairy-free formulas for babies. I don't know if I can mention brands on here, one just came out, it's an almond- based product for toddlers, there's pea-based.

Dr. Greenberg: There are options for getting a baby off of cow or goat formula. If they're suffering from cradle cap, and particularly also with eczema, we get them off it, and a lot of times that can make a huge, huge difference in their skin. Also sugar, sugar feeds candida, and so if I'm not sure if there's a candida problem, I do ask patients with any sort of malassezia problem to reduce sugar in addition to the dairy, and that usually helps out a bit as well.

Jennifer: First of all, these are amazing suggestions, and I'm glad that, for someone who's realizing now that malassezia is a thing they need to pay attention to, not just staph or some of these other issues that we talk about, they also are being given this direction too, that this is more of a systemic issue. It's not just concentrated at the… right? Isn't that like, that's been the whole thing the entire time, for years and years. When I went to the dermatologist, it's like, “Oh, it's just on your skin. It's just your skin.” We're oriented to just think the problem is there, where we see a patch or a rash, and that's not the case. There's so much going on underneath the surface, and if you only address what's happening at the surface, you're missing a huge piece that may be why you're stuck in this sort of like management situation.

Dr. Greenberg: Absolutely, with these derm conditions, for so long, we've been poking at the skin, thinking that's where it's happening. There are things happening on the skin, there are things we know about, like too much fungus, too much bacteria, too high a pH, but yeah, the problem is happening on the inside. If you don't treat the inside, you're not getting at the root cause. That is, as we know, the fundamental problem with a lot of our conventional medicine is, we're just trying to suppress symptoms, we're not getting at the root cause. I think that's why your podcast is so important, and this whole field of naturopathic and functional medicine where we're going deeper, we keep asking why. Why, why is this happening? This doesn't make sense. That's where we start to get some of these answers and really address the underlying root cause.

Dr. Greenberg: I think with malassezia, I hope a lot more research gets done, and that we understand a lot of these pieces a lot better, but even while we're doing it, I mean, dandruff, you can totally clear it. Seb Derm of the face, absolutely cleared. The problem is though, you do need the right diagnosis. I would tell people like, “Ladies, if you're in your forties and you can't wear eye makeup for the past six months, because you've got these raccoon eyes, go back to your dermatologist or find somebody new who will investigate and look at if it's actually a Seb Derm problem,” because all the antibacterial stuff in the world is not going to touch a malassezia problem, and actually will make it worse because then you're killing off bacteria and leaving more room for yeast and fungus to grow.

Jennifer: Yeah, oh my goodness, thank you. Thank you. Thank you so much for all of these pearls of knowledge, Dr. Greenberg. I really appreciate it. Your practice is located, tell us where, you're in LA?

Dr. Greenberg: I'm physically based in Los Angeles, but I have licenses in California, Washington and Oregon. Actually because of COVID, I'm a hundred percent tele-health. Any patients who are in Washington, California, Oregon, I can treat them. People who are in other states, you can contact me with questions. I'll try to help you out, maybe find somebody in your area, or answer a question here or there.

Jennifer: Yeah, and I want to make sure they do know your website. It's integrativedermatologycenter.com. Of course, if you guys go over to the show notes, we'll have all of the links there for you. Also too, there's some great information, we've talked about LearnSkin platform as well, which Dr. Greenberg has been really… You created a whole series, you helped curate a whole series of work that's there for people to check out further about skin issues, which I think is a huge, huge benefit to the community. We'll put all the links there to make sure that people can get access to all of this, but I really appreciate your time, and I hope we can have you back again, so we can nerd out, and talk more about some of these different organisms.

Dr. Greenberg: I know, I'm like the pathogen person now, so happy to come back and talk about some more beasts that are on the skin or anything else really.

Jennifer: Perfect. Perfect. Well, thank you so much.

Dr. Greenberg: Thanks, Jen.