076: What You Need To Know About Acne, Accutane & Antibiotics w/ Dr. Raja Sivamani

Acne is typically treated with antibiotics, which can have an impact on the gut microbiome. My guest today will explain how, as well as suggest other potential solutions for acne.

Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android

My guest today is Dr. Raja Sivamani, a board-certified dermatologist who practices at Pacific Skin Institute.

He is an Adjunct Associate Professor of Clinical Dermatology at the University of California, Davis and Director of Clinical Research and the Clinical Trials Unit. He is also an Adjunct Assistant Professor in the Department of Biological Sciences at the California State University, Sacramento.

Dr. Sivamani engages in clinical practice as well as both clinical and translational research that integrates bioengineering, nutrition, plant science, cosmetics, and skin biology. With training in both Allopathic and Ayurvedic medicine, he takes a holistic approach to his patients and in his research.

Join us as we talk about acne, accutane, antibiotics, and Ayurveda.

Have you used a more holistic approach to treat your acne? Tell me about it in the comments!

In this episode:

• How does accutane change the microbiome of the skin?
• Can shifting the lipid makeup of the skin have impacts down the road?
• If you are on accutane, what should you keep in mind?
• Long-term use of isotretinoin
• Why are antibiotics used to treat skin issues?

Quotes

“We've been doing research on isotretinoin. It does shift the way your fats and lipids on the skin are being expressed. And in doing so, it shifts the inflammatory profile on the skin, and, in fact, it will shift the microbiome.” [4:43]

“What you read online is all about high-dose isotretinoin. There's actually a way to do it low dose so it doesn't tax your system as much.” [12:32]

“Isotretinoin is a class of medications called retinoids. It will increase the triglycerides in your blood.” [12:57]

“Is diet going to take someone with severe acne and make them totally better? No, it's not. But it's part of the equation.” [23:13]

Links

Find Dr. Sivamani online

Dermveda

076: What You Need To Know About Acne, Accutane & Antibiotics w/ Dr. Raja Sivamani FULL TRANSCRIPT

Jennifer: Hello everyone. Welcome back. Today I have a very special guest with me. And this interview to be entirely honest with you guys, has been a long time in the making like months and months and months and so my persistence has finally paid off and I have gotten this doctor here to talk to you today and I'm really excited for us to dive into some of the information about medications that can be used that then can play a role in disrupting the microbiome in the gut, on the skin. I think you guys will find this very, very fascinating. His name is Dr Raja Sivamani. He's a board certified dermatologist and practices at Pacific Skin Institute. He is an adjunct associate professor of clinical dermatology at the University of California Davis and director of clinical research and the clinical trials unit. He is also an adjunct adjunct assistant professor in the Department of Biological Sciences at the California State University Sacramento. He engages in clinical practice as well as both clinical and translational research that integrates bioengineering, nutrition, plant science, cosmetics and skin biology. With training in both allopathic and ayurvedic medicine. Dr. Sivamani takes a holistic approach to his patients and in his research. And so long story Short, Dr. Sivamani knows his stuff, he knows a lot of stuff and I am so glad that he could join us. Thank you so much for being here.

Dr. Sivamani: Oh Jennifer, that was such a wonderful introduction. You've got me a little red actually from saying all those things. But I'm really excited to get on and talk to you about, you know, skin-related topics. I think there's so much that we could talk about. So I'm excited to spend some time with you.

Jennifer: Absolutely. So we were talking before this interview about the connection between certain drugs and how they could potentially throw off the microbiomes. We'll put that in plurality because there are microbiomes in the body. The one that you brought up, which would be a great place to start would be with the product called Acutane, which has a lot to do with acne. I get asked a lot about acne. So can you talk to us a little bit about what the deal is with accutane or was, I guess, cause you were saying it's actually not accutane anymore. That's not how people would call it. And how exactly would that disrupt or change the microbiome of your skin?

Dr. Sivamani: Well, this is a really interesting topic because Isotretinoin either elicits a really visceral bad reaction and a lot of folks or it elicits a good reaction in some folks, well believe it or not, but to start with, yes, accutane was the brand name for isotretinoin. And so that brand name doesn't exist, but the branding was so strong that many of us still call it accutane. But the actual brands now that basically, it's the same medication, isotretinoin, the names have changed. So your doctor might call it isotretinoin. But to go to what you're saying, I do a lot of work on the gut-skin axis and we look at things like nutrition, long-term effects of antibiotics. How can we reduce antibiotic use? And so this is where isotretinoin really comes into play. To more directly answer your question on how does isotretinoin affect the skin; it's pretty interesting. Isotretinoin has this ability to have a prolonged change in your skin in that we know that if people take isotretinoin, it's one of the few things in medicine. In medicine, especially the western approach to medicine, a lot of the medications are symptomatic care. They still will change trajectories of health and they can change cardiovascular risks. They can change diabetic risk. You know, if you take medications, there are few things that you'd take for a temporary bit of time and then you take away and the disease is changed forever. And isotretinoin is one of those few ones where if you take it for a short burst of time, and we should talk about this because there are ways, there are different nuances too. It's not everything that you read online, but you take it for a short period of time. You can actually potentially get rid of your acne forever. And you know, just even saying that is kind of mind blowing. And it does shift. We've been doing research on isotretinoin. It does shift the way your skin's, what we call fats, lipids on the skin are being expressed. And in doing so, it shifts the inflammatory profile on the skin and in fact it will shift the microbiome. And you know, there's some early studies looking at that, but you know, we need to do more studies to understand exactly how that shift occurs. But we know that it definitely shifts the lipids on the skin and lipids act as foods in many cases for the skin's bacteria. So that is one of the ways we know that isotretinoin is working.

Jennifer: Do you feel that it also has some sort of impact on the microbiome of the gut as well?

Dr. Sivamani: You know, that's a really great question and maybe to answer that, I can take a step back and say one of the things that we give for acne commonly, if you go to most physicians, especially if they're MD, DO trained, one of the things that is classically been a really common medication is antibiotics and antibiotics are lifesaving when you have an infection, but they also have this anti-inflammatory role and they work really well for acne. And so that's usually one of the first things that's given out. We now know that even short term exposures to antibiotics do shift the gut microbiome. Now that in and of itself doesn't necessarily mean that's a bad thing, especially if someone's struggling with acne and struggling with bullying or struggling with psychological issues and you're able to get it under control that obviously you have to balance things. But we're looking for different ways to treat acne and you know, we can talk a tiny bit about nutrition and the role of nutrition too in all of this. And this is where accutane comes in. So accutane, especially if people have really severe acne, you're looking at prolonged courses of things like antibiotics are, and we're trying to find other anti-inflammatories. But if you have really bad acne it becomes a challenge. And that's where isotretinoin when you give it to someone, you can really control their acne. Now in terms of the gut microbiome, it's a great question. It probably is shifting the gut microbiome. I don't have specific data on the gut itself. The stuff that we've been looking at has been looking at more shifts in the blood lipids, which are the, you know, the fats in the blood and then also what happens at the skin level. But I wouldn't be surprised and it's an area of ongoing study that we're even going to be looking at is what happens at the gut level.

Jennifer: Let me get this straight. Cause this is really interesting to me. When I was in high school, I took tetracycline for my acne.

Dr. Sivamani: Right. Actually, it's really common. That family of medications is very common.

Jennifer: Yes. And so fortunately I was able to get rid of my bad acne with the tetracycline and didn't end up down the accutane route. But it's interesting that accutane is affecting the lipids. So for those of you who are listening, and I'm not entirely certain how much we discuss this on the podcast so far, but I call them bugs. But the bugs on your skin actually, they thrive on fat, they thrive on the lipids. It's not like the bugs in the gut that love to eat fiber. It's a little bit different. And so is it possible that in shifting the lipid makeup of the skin microbiome, could that have negative impacts down the road?

Dr. Sivamani: I think this is a great question because it can have negative or positive impacts depending on your situation. And you're absolutely right. So when you look at the skin microbiome and you look at the genome project, when it was originally done and they did a lot of mapping on the microbiome, a lot of the original work was in the gut. But when they turned their attention to the skin, it was very fascinating. Every single part of your body anatomically will end up being slightly different. And so, you know, we have a lot of what we call microbes, which includes you know, parasites. Such a loaded word, but you actually have good parasites that live on your skin. You have fungi and you also have bacteria and their patterned on the skin in a very unique way. So when you look at the oily areas on the skin, so say the face, the upper back, the upper chest, the areas where you typically can get acne as well. We know that there's a different bacterial makeup of the dominant bacteria in those areas as compared to say farther down your arms or farther down your trunk, you know, the lower abdomen or if it's on your back or on your legs. And then if you look at the moist areas in between your toes, and I'm sure, you know, many of us could do the whiff test and know that the bacteria there are probably different. But if you think about like the armpits the groin areas, in between the toe webs, especially when things can stay moist, the bacteria there are different again. And so and the question is, well, so we now know there's a microbiome. What's patterning that microbiome? Because just knowing that there's a microbiome isn't the full story. We need to know what's controlling the microbiome, how's the microbiome interacting and how is it actually being nurtured at the skin level? And it turns out, and it might not be the full story, but part of that story is the lipids that are on your skin absolutely serve as food or serve as a supportive agent for the bacteria that tend to be there. And specifically if you look at the oily areas, cause we're talking a bit about acne, the bacteria that's been long thought of as the culprit. And by the way, it's still not totally clear cut that it's the culprit. It was originally called P acnes. They changed the name the, the name is now instead of propionibacterium acnes it's been changed to Cutibacterium acnes. It is very lipophyllic meaning that it thrives off of lipids. And so it's no wonder that it tends to be over-represented or I should say highly represented in the areas of the skin where you have a lot of lipids. And so if you take any sort of a medication, whether it's say isotretinoin there are other medications though that can also reduce lipids and change the profile you're probably going to be shifting the bacteria on your skin as a side effect or maybe it's your intended effect. And so there's definitely an interplay there between the microbiome and the lipidome as we call it.

Jennifer: Somebody who's taking or has taken accutane, you had mentioned that it shifts the lipid profile in the blood. Is there anything that you have to be on the lookout for? That you should keep in mind if, I mean, because most people are thinking it's just affecting their skin. And now what you're saying is no, actually internally we're seeing this shift. Is there anything we should keep in mind as far as it shifting that plasma lipid makeup?

Dr. Sivamani: So it does shift the plasma lipids as well. And you know, one of the funny side effects and I definitely take a very holistic approach cause I have an Ayurvedic background and we have prolonged conversations about nutrition, supplements that have early evidence for acne. And then we also talk about, you know, different lifestyle changes that people can do. And of course when people go on isotretinoin I think it'd be really good for listeners to realize that what you read online is all about high dose isotretinoin. There's actually a way to do it low dose so it doesn't tax your system as much. That's a different approach. And you know, if you can find a board certified dermatologist, they can definitely talk more about this. But one thing I will say with Isotretinoin, it definitely will shift your lipid in the blood and sometimes it will increase what we call the triglycerides. Cause isotretinoin is a class of medications called retinoids. It will increase the triglycerides in your blood. You know, a funny side effect Jennifer is that when I put teenagers on isotretinoin and we follow their lipids, it's amazing how quickly they cut out the fast food when they see that little blip and and they start eating right. It's a great motivator to get them to start eating better as well. It's not a permanent shift though from all the research that we're seeing. Once you get off the isotretinoin, your liquids go back to what they were before.

Jennifer: Okay. And do you find that there are any downsides longterm that if someone had used this in their past and maybe now they're struggling with psoriasis or Eczema or Rosacea, is this something that they should mention to a practitioner that they're working with that, hey, you know, I actually did have a history of accutane use.

Dr. Sivamani: Now with one of the things that isotretinoin can do is it can typically shift how oily you are but that's usually only during the time period that you're on it. Cause once you come off of it for whatever reason you might not be as oily going forward. But usually when it comes to things like other conditions like psoriasis. Psoriasis actually, typically we use retinoids. Isotretinoin doesn't work that great for psoriasis. So usually that's not an issue. In terms of longterm impacts with Isotretinoin, we don't see too many longterm impacts. Now, I do realize that when you read online, you'll get a lot of folks about mood shifts. There's a big controversy about inflammatory bowel disease, which has largely been disproven now. Cause you know, as dermatologists we were very concerned about is there a link there? And it turns out that a lot of those folks that ended up getting inflammatory bowel disease had compounding factors. So it's not that it leads to this longterm issue. We actually don't see too many longterm issues, although there's quite a bit of conversation around that. Even with things like Eczema, maybe some folks might get a bit drier on their skin in general and they might have Eczema that has flared. But, you know, the truth is there are so many lifestyle effects that we just don't talk about even with Eczema, that they are very good ways to approach these. It's good to let your doctor know that you've been on isotretinoin, the previously brand name of accutane, but we don't see longterm effects that affect people for a prolonged period of time that, that truly holds up with scientific studies.

Jennifer: And I wanted to ask you about tetracycline since I was the one that mentioned that.

Dr. Sivamani: We should talk about that.

Jennifer: Yes, definitely because it's very commonly used and I believe from my research with Perioral dermatitis that that class, and correct me if I'm wrong because I'm not a doctor, but that class tends to be the one that is used for people with Perioral, which is a real pain in the behind to get rid of. Any thoughts on tetracycline and using that with acne or if you have any thoughts on perioral dermatitis too, I think that would be very appreciated. Much appreciated for the by those who have that or struggling with it now.

Dr. Sivamani: I love that you're talking about antibiotics. So tetracycline was the antibiotic itself. That's actually not as available nowadays because it had a lot of GI issues. Now there's Doxycyclin and minocycline. The new guidelines are to reduce antibiotic exposure so that you're getting people off within three months. This may be really relevant to a lot of listeners, if you're an adult woman with acne or you're a teenager that's female with acne, my first line no longer is actually antibiotics. Especially if you're in your 20s and 30s. There's a big hormonal component and now they have different medications that can address that, that are non antibiotic. But to go to your point about antibiotics, they definitely shift the gut microbiome. And we know that even a short term exposure to the tetracyclines will shift the gut microbiome. Now the good news is that at six months it seems that there is largely a lot of recovery of the gut microbiome. And so what I tell a lot of my patients is to make sure they continue to eat a lot of plant-based foods and fruits and vegetables. Try to get about nine servings a week if you can. That's really important. And then secondly having a probiotic on board has been shown to reduce people from developing things like vaginal candidiasis, like yeast infections. And so we know that if you can take the antibiotic with a probiotic, then that does not only become helpful for the side effects, but there are some specific probiotics. There's one specific probiotic that was studied in a small study that showed that it actually improved how your acne improved. It works synergistically with the antibiotic and the goal is to try to get people off these antibiotics.

Jennifer: Absolutely. What is it about the antibiotics that we decided to use that in order to address acne? Is it that it is shifting the microbiome on the skin? Obviously it's shifting the microbiome of the gut, but was that the intention where we realizing when that happened, like, oh, we probably have bugs in the gut that shouldn't be there, so let's take this medicine and look our face clears up. Or is it more the anti-inflammatory aspect of the antibiotic? Like just any thoughts that you have around that?

Jennifer: Yes, I think that credit for realizing that the gut had a role really can't go to western medicine first. It has to go to traditional Chinese medicine and Ayurvedic medicine cause they have been talking about the gut for a long time. But in terms of the reasons we use these antibiotics, it's because it's not an infection. Some people think there's an infection in acne. It's the anti-inflammatory. It's funny Jennifer, it's just that we haven't come up with a good alternative agent that's anti-inflammatory yet, but there's a few things on the horizon that are now emerging. And so we've fallen back on antibiotics and we didn't realize the unintended consequences that it was going to shift the good bacteria in your body. Now if you have a bonafide infection. Absolutely. That's where antibiotics, no question is super important. In an anti-inflammatory set up, I do think there's going to be other agents that are going to eventually come and replace replace the antibiotics. So if one of the areas that people are looking at now very intensely is different probiotics and probiotics you know, it depends on the exact bacteria and the formulations, but I think there's some promising things on the horizon with probiotics that may eventually help us reduce the antibiotic use. But we're using it primarily for anti-inflammatory reasons.

Jennifer: And if someone's listening to this and they're like, okay, so if it's more anti-inflammatory, what are some recommendations that you have for patients in that boat? Maybe from like an Ayurvedic perspective that they could take action on in their daily life. That may also be helpful.

Dr. Sivamani: I think this is going to be fantastic cause I always love to try to bridge the Ayurvedic principles into the western principles. So you know, from a Western perspective, you just label it acne and there are actually several subtypes of acne. You can have what's known as comedonal acne, which has a lot of plugged pores, you produce a lot of oil, so you get a lot of black heads and whitehead's what we call comedones. You can also get an inflammatory form of acne with what we call papules, which are those red bumps, pustules, which are, you know, the pus filled bumps and sometimes these deeper painful nodules. The way Ayurveda looks at the body is slightly different, but actually it really beautifully integrates with the western approach when you start building these bridges. So the ayurvedic approaches, just to break it down to the most basic approach, and this is kind of a rudimentary description. There are these three physiological energies that control how the body reacts and they're known as the doshas. And so when someone has acne, acne is not, acne is not acne, neither from Western medicine because there are nuances. But from Ayurvedic medicine especially. The, the two doshas that are involved are known as Pitta and Kapha. Kapha really relates to structure, the production of things like lipids and oils, especially when you start looking at how that correlates to the Western and research paradigm. And Pitta is related to inflammation. So when you have these two doses that are out of balance, we start thinking about things that might, you know, not add to a Kaphic imbalance. Funny enough, it's going to be things that create an insulin spike. So the Ayurvedic approach is that anything that's gonna lead to a Kaphic imbalance would create an insulin spike. And so things like sugars, high-glycemic index foods, and now we're starting to see, there's a lot of epidemiological studies around milk especially skim milk. All of these cause insulin spikes. And so you start to see these beautiful bridges going between the two different traditions that maybe they're not so different. Yes, the education and the way they approach the body is different. So, you know, if you are totally trained in western medicine and you're looking at Ayurvedic medicine, you might say, what is this? But actually if you delve into Ayurvedic Medicine, you say, Oh my God, these are beautiful bridges that actually come together. And so I definitely talk about diet. Now, is diet going to take someone with severe acne and make them totally better? No, it's not. But it's part of the equation. So, you know, some of the things that I talk to my patients about is reducing dairy intake. I take them off dairy altogether. There hasn't been a perspective study looking at taking dairy away and saying the acne got better. But there's so many epidemiological studies showing that that dairy probably has a role that I'm very comfortable taking people off dairy cause I know there are other nutritional agents that people can take. And also I talk about making sure that they try to have low glycemic glycemic index food. So what that means is, you know, stay away from the white breads or the, the quick simple refined sugars that come out of candies and whatnot and try to go after the more complex carbs, carbs like fruits and vegetables. And I hit an area that people don't realize is when you drink these sweetened teas, they are loaded with sugar. And there was a recent epidemiological study that just came out of Asia showing that that kids that drank more sweetened teas had a higher incidence of having acne as well. And so then there's all these hidden sugars that we have in our diet that I try to make a point to have people talk about, think about. And I definitely get people off dairy. It's amazing teenage boys, teenage girls, they are willing to stop dairy because the acne is so profound. And I think it also reduces the need for medications as much. And then the last little bit is a lot of folks are trying to put on weight, especially when you're in your teens as a male. Lot of people are going to the gym as a young male, you know, into the early twenties and some of them are struggling with acne. I get them off the whey protein cause a lot of people are taking whey protein supplements. We always think, oh it's anabolic steroids or something. But actually whey protein has been shown in a couple of case series, not a full study. Like when they've taken them off the way their acne got better. And then when they put them back on the way their acne exploded again. And so it's something that I talked to folks about and we've done research on the milk proteins and we know the milk proteins do stimulate the oil glands. So I think, you know, those are a couple of ways of bridging Ayurveda and Western medicine together to come up with a holistic conversation with my patients.

Dr. Sivamani: Wow. This has been such a good conversation. I feel like we could go on and on and on about this, but people love their 30 minutes. I let this conversation go on longer cause I have thoroughly been enjoying it and I hope that we can have you come back sometime cause I'm sure that this is, this is one area of your expertise that we can talk about, but there's likely many others. I really want to share what you're doing as well because I think it's of tremendous value to everyone who is listening. So whether you're a patient or you are a practitioner or you're more interested in the practitioner end of things. So you started a website called learnskin.com and that is geared more toward helping educate practitioners. And looking at the skin from a more integrative perspective.

Dr. Sivamani: Yeah, we're really excited about learnskin.com. It was started by my wife Venita Sivamani and then she has a group of dermatologists that she worked with. And I serve as a medical editor because I think it's really important to make that what people are reading is at least vetted and based on, you know, medical literature and it's based on scientific facts as much as we, you know, we want to talk about a lot of the potential for a role of multiple aspects and integrative approaches, I think it's really important to still be rooted in a scientific approach. And the whole principle of learnskin we're very excited about it, is that we bring the information online, make it easy for people to access and it's an integrative approach. And so it's not just an online approach though. There's also the integrative dermatology symposium. And the next one is, you know, we do it every fall. You can go to integrativedermatologysymposium.com to learn more about that. So we have online classes, online articles, continuing medical education for folks that, especially from a practitioners that want higher level content and they can get their CMEs and have fun with it. And we're also putting on a lot of summits that are open to the public to come in and also practitioners to come in so that we can really have open conversations about how they might approach things with their patients. Because I think a lot of what we learn in medicine isn't just what we're reading in textbooks. It's from experience too cause there's a lot of gray area where it's really helpful to hear what other people are doing. And so we're trying to build that community

Jennifer: And I think that's so needed right now because people want this information are tired of suffering. I suffered, I know what this is like. I was like why doesn't my dermatologist understand any of this? Like the only option she can give me is the steroid cream. Like that just seems crazy to me in this day and age. So I recognize that part of it is there, there are so many other things, but we need to create a way for people to learn about it because textbooks are written what, two years before they're published.It's difficult to also keep up on research. It takes a lot of time and you have to really want to be interested in it in order to do it. And I love the fact that you are and that you're sharing that information to help educate about all these other options.

Jennifer: And then for the consumers who are also interested and just looking at ingredients and understanding their skin from a different perspective, they can check out dermveda.com. And that's a really great website with a lot of amazing information as well. I think it's great that you guys are supporting both the patients as well as the practitioners and together we're all helping to move this movement forward. I love it. I'm just so appreciative that you were able to join us and we were able to figure this out because this has literally been a conversation probably almost eight months in the making at this point.

Dr. Sivamani: Yeah, it's definitely taken some time. I can end by saying that, you know, when you're thinking about your physicians and thinking about skincar are Dermatologists, very thoughtful, one thing that dermatologists are becoming much more, and we've always thought about science and we've always thought about medicine. We're always thinking about what is the best evidence that we can find. So what dermatologists are doing is as studies come out, our understanding and landscape is shifting. And so you'll find much more of the field now understanding that nutrition plays a role, that the microbiome plays a role. And it's one of the really nice things about scientific discovery is that the whole field will shift together. So, you know, the dermatology knowledge of 20 years ago has really shifted. So the dermatologist of today has become much more refined in the way they gather research and the way they integrate research into their practice. So I'm really excited about it as one of my student mentees tells me it's a great time to be alive.

Jennifer: Absolutely. It is. It's super exciting and I'm glad that we're all on the same team together. So thank you so much for joining us, Dr. Sivamani. I really appreciate you joining us here, sharing what you know and I look forward to having you back.

Dr. Sivamani: My pleasure.