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Are you struggling with a super itchy skin rash that looks like eczema? If gluten seems to be a trigger – you might be dealing with dermatitis herpetiformis!
Dermatitis herpetiformis (DH) is a rare skin rash that starts off as incredibly itchy, small blisters that eventually start to become open sores due to constant scratching.
This rash is generally considered to be MORE ITCHY than eczema, and is commonly found in the creases of elbows, knees, and buttocks.
What causes DH, you might ask? The answer is surprising: Gluten. Yes, dermatitis herpetiformis is a gluten rash – the skin manifestation of celiac disease. In fact, eliminating gluten from your diet and skincare is necessary to find relief.
Joining me to talk about the link between gluten, dermatitis herpetiformis, and celiac disease is fan-favorite guest Dr. Peter Lio, who is a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine.
He received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, Dr. Lio received formal training in acupuncture. Dr. Lio has written a textbook on Integrative Dermatology and has published over 100 papers.
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In This Episode:
- What is dermatitis herpetiformis (DH)?
- Dermatitis herpetiformis symptoms
- How is this gluten rash diagnosed?
- Other clues that you may have dermatitis herpetiformis (e.g. altered oral health)
- Autoimmune conditions linked to this celiac rash
- Can removing gluten from your diet improve dermatitis herpetiformis symptoms?
- Dermatitis herpetiformis treatment options
- Nutrient deficiencies associated with celiac disease
- Should you use gluten-free skincare if you have DH?
Quotes
“Dermatitis herpetiformis, or DH, is really an inflammatory autoimmune disease that actually results in tiny blisters, although when most patients see it, they tend to look more eczematous…It's incredibly itchy.”
“[The itch] can be absolutely crazy. They can be going nuts where they're scratching. And again, it's these funny areas, elbows, knees, buttocks, and they're so uncomfortable. They can't really seem to get to the itch. I find it's even more intense and deeper in general than atopic dermatitis.”
Links
Find Dr. Lio online | Twitter | Facebook
Healthy Skin Show ep. 216: Could Your Rash Be A Sign Of Lymphoma? w/ Dr. Peter Lio
Dermatitis Herpetiformis (NIDDK)
Dermatitis Herpetiformis (NIH)
Dermatitis Herpetiformis: Novel Perspectives
352: Dermatitis Herpetiformis (Celiac Gluten Rash) Symptoms + Treatment w/ Dr. Peter Lio {FULL TRANSCRIPT}
Jennifer Fugo (00:07.151)
Dr. Lio, I’m not only excited and honored to have you back on the show, but you and I are gonna talk about a topic that has never in like five years of the entire show been discussed, which is dermatitis herpetiformis. And I thought of you, because I got so many requests about this, because you have such a great way of breaking down some of these conditions that are lesser known or are more complex. So tell us, what is dermatitis herpetiformis?
Peter Lio (00:40.574)
So it is an interesting condition. First, thanks for having me back. It's always so fun to be with you and talk about this. And this is a really important subject because it is truly at the interface of skin and gut and diet, right? I mean, it's right in our wheelhouse, which is so fun. So dermatitis herpetiformis, or DH, is really an inflammatory autoimmune disease that actually results in tiny blisters, although most patients, when they see it, they tend to look more eczematous. In fact, it can be one of the things that can masquerade, or trick us that it's actually eczema, because they tend to scratch at them when they're tiny so you don't often see them as true blisters, but just more open sores and kind of irritated skin. It's incredibly itchy. And what's remarkable about it is that it is fairly rare, but it's an important signpost in thinking about the differential possibilities for some of the things going on in our skin.
It is really the visible manifestation, the skin manifestation, of celiac disease. And we know celiac is this condition where you make a particular kind of antibody, IgA antibody, to gluten and specifically the part of gluten called gliadin. And this also cross-reacts with our skin. So we can actually see when patients are eating gluten, then they can develop this gluten rash. And what's remarkable is when they stop, if they're really good, it disappears. So it's sort of the archetype of the dream of, what if diet were driving my skin problem and could I take this out of my diet to get better? And the answer here is yes, almost a hundred percent yes. It's like really perfectly connected, as opposed to so many of the things we talk about, where diet has an important influence and can play different roles, but often gets sort of thrown in there and people keep looking for stuff in the diet even when there's nothing there. This is one of those cases where it is the whole story.
Jennifer Fugo (02:19.803)
So for someone who, let's just say, they notice they have this gluten rash, come across information on the internet and they go, maybe I should go gluten-free. They take gluten out for, I don't know, even let's just say like two weeks, 30 days, and they notice an improvement. Would that be important for them to tell you as the dermatologist if they go to see you and they're showing you their skin, is that helpful for you to know?
Peter Lio (02:48.426)
It's definitely helpful. The biggest thing we have to differentiate it from is eczema, and that’s in my experience, or allergic contact dermatitis as well, if they're allergic to something in their environment. And of course, we know that the world is never as clean as in the textbooks. Sometimes people have multiple things. I have patients who really have allergic contact dermatitis and dermatitis herpetiformis, and you're saying, wait, why are you not getting fully better? And so we have to do a couple of things to figure it all out and unravel it. But you're absolutely right. If they cut a food and they find that it makes it, and really here it should be
dramatically better, it should be essentially clear. Now, the one caveat, and you know this better than anybody, is that gluten is hidden in all sorts of foods. So sometimes people say, well, I stopped eating bread and it got better. And it's like, eh, there's a lot of gluten you're still exposed to. So that might not be enough. But if you're truly doing a gluten-free diet and you get better, that would be important.
The way that we diagnose it though, almost always is gonna be a skin biopsy. We're gonna take a piece of skin, we actually do a stain, and we can see the IgA antibodies lined up. You can actually see them in the skin. I mean, it's really, really beautiful and clear. It's fluorescent, so you can actually, if you look online, you can see some beautiful pictures of the beautiful clumps of IgA that are binding to those proteins, and you can see what's happening, we think, is that it damages it so that the skin can't hold on, and it opens up, and fluid fills in, that's what's happening with an autoimmune blistering disease. The skin starts to literally fall apart, fluid collects, you get a blister, and then it opens up and becomes a sore.
Jennifer Fugo (04:11.703)
And is the staining of a biopsy, is that like a routine part of a biopsy or is that something that the dermatologist has to ask for?
Peter Lio (04:22.062)
Great point, because absolutely, if you just do a regular old biopsy for H&E stain, the traditional staining that we do, that will not show dermatitis herpetiformis. They actually have to do specific immunofluorescence. So they have to go in thinking, and I actually have to put it in a special medium. If you put it in formaldehyde, it often will not work correctly. So we put it in like a saline type or a special medium called Michelle's medium and we send that, and then we tell them we need immunofluorescence with our concern of an autoimmune blistering disease including dermatitis herpetiformis. So then they can tell us right away. Now if we didn't do that, they still might get an idea from the regular H&E stain. They might say, you know, this is suspicious for it. But other things that help us are the distribution on the body. It loves elbows, knees, and buttocks. The butt is itchy. And that's a little different than eczema, right? The eczema is usually the other sides. It's more the flexural areas. Although again, it can be a little confusing at times.
And sometimes if I look, especially with my little scope, I can see tiny blisters there and I'll say, hmm, this looks more blistery rather than pure eczema, even though, again, clinically, just looking in the room, it might just look kind of open and scratched and irritated.
Jennifer Fugo (05:25.347)
Now, if you were to, say, run this special type of biopsy staining, do you think it's also helpful to run a celiac blood panel as well as genetic testing? Is that something that a dermatologist would do, or would you refer them back to a primary care doctor or a gastroenterologist to have that done?
Peter Lio (05:45.582)
Typically I'll do the celiac disease panel, which is a bunch of antibodies in the blood. I usually don't do genetics because usually if they have the IgA in their blood, that will also lock down the diagnosis and it is good to know. While we often see patients with both GI issues and the skin issues, it's absolutely true that some of the patients truly just have skin issues. Their gut seems to be okay and we verify this by having them get scoped to make sure there's not some early changes in the gut, but some of them truly just have gluten skin symptoms. And I think the majority of patients with celiac disease only have the gut and don't have the skin. So it's not a very reliable indicator and we don't fully understand why we see it in some people and not in others.
Jennifer Fugo (06:24.391)
And I was going to mention that. As I was reading different papers to talk to you today, I read this quote, which I'll put in the references below this episode, that less than 20% of people with DH have symptoms of celiac disease (dermatitis herpetiformis celiac). So my assumption was that this person must have all of these GI complaints or some sort of reaction to gluten that's pretty odd. Like you said, you eat a piece of bread or you have a bowl of pasta and you feel horrible afterwards, but that's not necessarily the case. Like you said, if you are having some sort of reaction, like a gluten rash, maybe that could be helpful to tell the dermatologist, but you might not actually have that reaction of like, wow, something gastrointestinally is wrong here. I think that's important for folks to realize.
Another thing I wanted to just ask you about is I've also read that dentists, and I've interviewed a number of dentists on the show because I find the oral microbiome fascinating. And I talked with a dentist earlier last year who discussed that they can find signs of nutrient deficiencies in the mouth. But it sounds like dermatitis herpetiformis celiac could possibly have some oral signs like erosion impacting the mucosa in the tongue, maybe pain or a burning sensation, so if someone is also experiencing that. I find a lot of times people may go to a derm and say, like, I have a rash.
And they don't give other potential clues that could be helpful to you. Like you said, the gluten rash could look like eczema. So do you find that maybe it's a good idea, like if your dentist is also saying, hey, I'm seeing some weird changes here, and you're having this type of presentation, that could be helpful for a dermatologist to know if you’re thinking you have dermatitis herpetiformis vs eczema?
Peter Lio (08:24.542)
Absolutely, and you know, I try to ask those questions and be perceptive, but there's no doubt sometimes you're kind of in your zone, you're like, oh, I think it's just eczema. You're not even asking the key questions, you're not looking in the mouth all the time, which we really should, so you're right. Things like aphthous ulcers, you know, the canker sores, angular cheilitis, the lips can be very inflamed, cracked, fissured. They can be chronic and difficult to treat.
One of the things that's confusing too is that there may be some specific connections with the dermatitis herpetiformis celiac or with the IgA antibody. Some of it might be, as you said, secondary to low vitamins and minerals, because you actually have an absorption process in your gut. So now we have a couple of things that can compound, and that's maybe partially what's explaining the angular cheilitis. If you get deficient in certain vitamins, you may have that or may be more prone to it. So that's important. Dry skin, some nail and hair changes are also sometimes visible. And then specifically with the teeth, they can have thin enamel on their teeth. So there can be specific findings.
Jennifer Fugo (09:20.073)
Oh, well this is just perfect, because like I said, it's helpful for someone to know what they should tell their dentist or their dermatologist or their doctor to try to get the appropriate diagnosis. I always think it's helpful when you can bring the right set of information. That's always helpful. And then I also noticed that there tends, because this is an autoimmune disease, usually the stats are once you're diagnosed with one autoimmune disease, it makes you more at risk to be diagnosed with more autoimmune diseases, unfortunately.
So you’re at greater risk for a second, for a third, which is unfortunate, but that tends to be the case, especially with women. So, are there other conditions that you find or have seen in your practice where someone might be diagnosed with DH, or they also have something else going on, prior or before getting this diagnosis, or maybe they develop something afterwards?
Peter Lio (10:16.682)
Yes, I think one of the hardest parts for us is that there are sometimes a personal or family history of other autoimmune diseases. So thyroid is the big one that I've seen, and it's really worth checking the thyroid function. Pernicious anemia, the vitamin B12 binding issue, type 1 diabetes, vitiligo, things like that. So we can see these associations, which makes it a little tricky. The other big piece that's really important, I think, for everybody thinking about this to know about is that if you have this condition, dermatitis herpetiformis celiac disease, and you don't cut gluten, you actually do have a much higher risk, something like five or ten times the risk, of getting a non-Hodgkin's lymphoma. And that's actually really strange. We don't fully understand why. We think it's kind of a chronic immuno-overstimulation.
So I've had patients sometimes who say, well, I don't care, you're going to treat my skin, I'm going to keep eating gluten. Which, we have to talk about this, because this is one of the most fascinating psychological pieces of this whole puzzle. But I'll say, listen, actually, it's not just about your skin. Maybe with medicine, I can get your skin better or comfortable enough, but you still have the risk as long as you're eating it and that can even happen in your gut. You can have a lymphoma in your gut, which is really scary.
Jennifer Fugo (11:20.551)
Wow, I had no idea. That is really scary. My goodness.
Peter Lio (11:26.13)
The psychology of it though is what's so fascinating to me. And again, dermatitis herpetiformis celiac is a pretty rare condition. So I think in this day and age, many people point to gluten early on, right? Gluten and dairy are kind of the two villains, and I love you, you talk so beautifully about it in so many of your episodes where you put it in perspective. And I do think, you know, they can be inflammatory. Some people truly have allergies. Some people really do have celiac or dermatitis herpetiformis celiac. They might have lactose intolerance. There are many reasons why to avoid those, of course. But I sometimes think they're just vilified unnecessarily by some people.
The remarkable thing though is so many of my eczema patients really would love to have a single food or foods to avoid. Sometimes they won't let go. I'm like, I know, I wish we had something. I don't know what to tell you. You've seen experts and I think we just have to treat you. I wish I could find the root cause, but we're often not able to yet. I mean, hopefully one day we're gonna be able to figure it out perfectly, but a lot of times we can't. So they're frustrated that I can't find something. The opposite effect is true here with these patients. And again, it's fairly rare. I only have a handful in my whole panel, but when I make the diagnosis, I'm usually excited. I'm over the moon. I'm like, the test was positive, we know what this is, this is unbelievable, we can just cut gluten as their dermatitis herpetiformis treatment plan. And now the world is so friendly to gluten-free people, you can go anywhere and get it. You know, in the 70s and 80s, it was brutal. You really didn't know what you were up against, but now, because it's so widespread, it's cheaper and easier.
And you know what happens, honest to goodness? They cry. Many patients start crying, and I say, wait, what's the problem? They go, I don't want this. I wanna eat bread. I wanna eat cookies. I wanna eat cake. I don't wanna have to deal with this. And I'm like but we know the root cause of your disease. We can fix it, just one type of food, and you can have gluten-free muffins and cookies and cakes, the world is…they're crying. They're so devastated. And they're saying, is this forever? What medicines can you give me? What drugs can you give me? And I'm like, I feel like I'm in a bizarre world. I have one half of my, well, most of my life, which is patients begging me not to use drugs and find some other way around this. They'll do anything. They'll move to the moon and go in a bubble for eczema. And then I have a group of patients where I have the answer I'm handing them on a silver platter and they don't want it. It's just the most remarkable, mind-bending thing.
Jennifer Fugo (13:17.639)
Oh my gosh. It is hard. I mean, I will say, because both of us, well, we're both Italian, and I will admit that when I found out that gluten was a problem, well, I think on one hand, I was relieved because I was so sick all the time. But on the other hand, and like you said, to your point about perspective, a lot has changed because I had to remove gluten in 2008. So the alternatives were awful. They were so bad and there wasn't many options. It was so hard. Now there's so many options. There's so many alternatives. There's products everywhere. You can order lots of things on the internet. You can go to restaurants. There's so many more options. Now granted, is it perfect? No, but there's so much more opportunity to live a much more normal life. But I can understand there is a grieving process with having to break up with gluten, because I certainly, I don't miss it so much anymore. But there are moments like when we're in Italy and I'm just like, oh, I would love to try that homemade tagliatelle, and it's like, no, gotta go for the gluten-free version.
Peter Lio (14:27.95)
And it's a great point. I don't mean to sound insensitive because it stinks to have any condition like dermatitis herpetiformis celiac and it's no fun. And of course the world is filled with all these things that have gluten anyway, so it is hard. So I never mean to minimize it, but only that it's so exciting to actually have an answer and they don't want that answer. And I get it, I get it. But it's just crazy. I wish the two groups of patients, they, I think the eczema patients would sell their soul to have that as the answer. They do it anyways. As you know, many eczema patients cut gluten and dairy just trying, and the classic response we hear from them is, it's a little better when I do this, right? It's like, yeah, it's probably not the whole thing, but you know you got to do whatever it takes to get you there. They would just love for that to be the whole story.
Jennifer Fugo (15:03.223)
Yeah, and I do want to just be very clear. This is gluten-free at a celiac level for life. This is not like we go gluten-free for two years and then try and reintroduce it and see how we do. And I would also just as a clinical nutritionist caution people against wheat sourdough bread because I realize it's fermented and it's supposed to help break down the gluten, but there's truly no good proof that it's completely gone. And this is an autoimmune disease, so I think it's worthwhile to mention. Just in your experience, if someone is like, okay, cool, I'm going to take gluten out for dermatitis herpetiformis, approximately how long do you have to be gluten-free to really see the skin clear up?
Peter Lio (15:52.778)
In my experience, it's actually pretty fast, so long as they're strict. And I love the way you pointed it out. It's different than just kind of, you know, comfortably gluten free and trying to avoid gluten or something like that. This really is being pretty crazy, reading labels, making sure, because even things like soy sauce and all sorts of different soups, they have gluten in there. So you have to be pretty intense. But in my experience, honestly, just a few weeks, at the most a month or two. In fact, if somebody came back at a month or two and said it's not much better, it's only a little better, I'd say you're missing something. And then I would, if they haven't already, I would refer them to somebody who has a lot of experience because I would expect it to happen pretty quickly.
Jennifer Fugo (16:29.912)
Just out of curiosity, because I think it's worthwhile to mention just because this is an autoimmune disease, and my own experience being involved with a celiac organization many years ago, if they are positive for DH, thus celiac essentially, do you also recommend that relatives get checked for celiac? Because my understanding is there's a greater risk.
Peter Lio (16:52.846)
I think that's a good point. You know, I think you're probably right and there definitely is a family connection with dermatitis herpetiformis celiac. Usually I haven't, but maybe I should. I usually just talk to the patient. I do make sure they see a gastroenterologist, even if they don't have any symptoms, because I want to make sure that they're being screened, it's possible later they would develop GI symptoms. So I want to make sure they're following up, at least having a consult visit with somebody, and hopefully they'll tell them if they feel like they should have family members do it. But I'm not sure on that. So that'd be something I'd love to look into and we can get back to the listeners.
Jennifer Fugo (17:21.015)
Also too, like if someone's in an acute situation, right, so they've got open wounds, like their skin is really angry and upset, that's great to go, well, it could take a few weeks, go gluten-free. Is there anything else to bring someone relief from the horrible itching? Is there other dermatitis herpetiformis treatment option in your toolbox that you might prescribe in the meantime while they're getting gluten out of their life?
Peter Lio (17:45.838)
Absolutely, and the truth is, nothing is great compared to taking the gluten out, because that's really what's driving this whole process. But sometimes people are miserable. Our dermatitis herpetiformis treatment of choice is the oral medicine called dapsone, which is kind of an old-fashioned antibiotic that really, we don't use it for many bacterial infections, it's almost always used for this kind of inflammation pattern. And it usually works within just a few days. Many people can really clear up.
And that's why it's so tricky because people, when they're feeling better on it, they'll say, oh, I can still have gluten, right? And I say, well, this funny lymphoma thing, we don't understand it. What's also remarkable about dapsone is that there is a topical version of it too, it's used for acne. And so sometimes I'll give people both. I'll say, you can take the pill and you can put to these trouble spots, the topical. We don't necessarily know if that is really helping. And it is technically off-label, but I do have samples of it. Sometimes I'll give people that.
Sometimes we'll also use topical steroids to help with a gluten rash, and even strong antihistamines can kind of help you sleep at night, to kind of knock you out a little bit. But the real secret I think is really getting them on the dapsone and avoiding the gluten.
Jennifer Fugo (18:46.831)
So what I'm hearing from you, then, is that the itching is fairly intense with this.
Peter Lio (18:54.026)
It can be absolutely crazy. They can be going nuts where they're scratching. And again, the dermatitis herpetiformis celiac gluten rashes are found in these funny areas – elbows, knees, buttocks – and they're so uncomfortable. They can't really seem to get to the itch. I find it's even more intense and deeper in general than atopic dermatitis. And you know, those patients are miserable too, they're among the worst, and prurigo patients, but this may be, the ones I've seen, are among the highest itch. And it's just so intense and so localized. They're going crazy.
Jennifer Fugo (19:19.511)
That's good for people to know too, because I know with other episodes when we've acknowledged the severity of certain dermatitis herpetiformis symptoms, especially itchiness, because you know, and I had that lovely opportunity to be in your office and watch you work with patients. The one thing that I deeply appreciated was the fact that you could acknowledge what they were going through. You know, you didn't dismiss their daily experience or the pain or discomfort. And I think it's really helpful. A lot of listeners of the show have deeply appreciated when guests acknowledged how bad some of these dermatitis herpetiformis symptoms, and debilitating, some of them can be. So I appreciate you for that.
And I wanted to mention one quick thing, because I realized as we were talking and you mentioned, you made a really good point about how, with celiac disease, some of the signs are anemia. So you can have iron deficiency anemia. You can also have megaloblastic anemia, which is a little sometimes tricky to figure out because you have to look at B12, you have to look at vitamin B12, vitamin B6, and folate. And sometimes you can have multiples that are low or one is really off. Sometimes folate deficiency or B12 deficiency can mask the other.
Jennifer Fugo (20:38.829)
So those are important to know. And I would just say as a clinical nutritionist, if you do end up with this diagnosis, to make sure that somebody, whether it's a gastroenterologist or your PCP or somebody, is looking at those markers just to make sure. And vitamin D can also be low in celiac disease as well. So it's always important to get those levels checked to make sure that you're supplementing appropriately and you're handling your diet appropriately.
So my last question, because I really sat with this condition and I’m oftentimes asked, well, if I'm gonna go gluten-free, do I need to make sure my skincare is gluten-free? And so normally the answer is no, because the reaction with gluten sensitivity and celiac disease is in the GI tract. But then I thought about this, you're actually having an autoimmune reaction at the skin. Granted, it doesn't originate there, but I figured you'd be the best person to ask since oats are oftentimes used in products. They may not be gluten-free oats, which is a whole other thing to know, too, if you get this dermatitis herpetiformis celiac diagnosis, you’ve got to be really careful with oats because they tend to be contaminated due to processing. So if someone is diagnosed with DH, do they have to worry about skin contact with gluten in products or just in general?
Peter Lio (22:05.286)
I think it's a really important question, and I don't know if there is general consensus in the dermatology community, but I'll tell you my approach. I actually do think you're right, because we know the tiniest trace amounts of gluten can trigger this reaction. And because, again, the stakes are, itch is terrible and the rash is terrible, but even beyond that, this weird looming thing of lymphoma which makes me a little nervous.
So yes, I do tell people I'd like you to use gluten-free products and fortunately again, many products now have a gluten-free, they've been certified, and even if they use oatmeal, they'll say this is certified gluten-free oatmeal, which is great. So as best they can. Now in a pinch, if somebody had a product they weren't sure of or were going to use, some kind of makeup, I suppose it's not too worrisome, and it's unlikely they're going to have a terrible reaction from a small exposure to something especially that's maybe co-processed or unknown. But I do think we should do everything in our power because you know, something like a lymphoma would be pretty intense and I don't want anyone to go through that unnecessarily.
Jennifer Fugo (22:57.487)
Yeah, and I would also say especially what you put on your lips, whether it's some sort of balm or lipstick, because they do put gluten and other things in. We ingest a lot of what we put on our lips, so you do definitely have to be careful if you have dermatitis herpetiformis vs eczema. And fortunately, there's a lot of, there's several celiac websites, different organizations in the United States that you can go to. And I can put some of those in the resources for this episode to help anybody that may be looking for some guidance around how to, because you have to essentially, like it's essentially celiac disease, so you have to treat it as such, even though there may not be, hopefully, a GI component. Hopefully, fingers crossed, right? That's the goal. Any final thoughts, Dr. Lio, for those who are diagnosed with this or are thinking like, wow, this sounds like me?
Peter Lio (23:51.822)
Definitely see a dermatologist, tell them what you're thinking about. And you know, dermatitis herpetiformis celiac is fairly easy to diagnose. It's just often forgotten. In fact, I'll never forget as a, I think a first year, maybe a second year medical student when we were still in class, they told the story of a patient that had seen, you know, eight or nine different specialists and nobody could figure it out. And then finally, the dermatologist biopsied and made the diagnosis. And this was a while ago, you know, now more than 20 years ago. And it was still considered a really rare condition. Very, very little was known about it. But that stuck with me for all the years, remembering just these kind of zebra cases where you're thinking, boy, no one can figure me out. Nothing's getting me better. And I've internalized that. When I inherit patients who have eczema or a rash that I don't understand, we really try to do a pretty full workup. We're gonna do a biopsy. We're gonna do blood work. We're really trying to find out if there is something because again, while the patients aren't always happy to hear it, it's good to know what something is. It's good to at least be able to define it and have parameters.
Sometimes I think the hardest thing is not knowing and not being sure. I had a patient where we were talking about the alpha-gal allergy from tick bite where they're allergic to meat, this whole thing. It was fascinating. And just again, just a few years ago, we didn't even know about this. So we're always learning, medicine keeps moving forward, and that's why we can't give up. I don't want people to lose faith or hope. We have to keep trying, keep getting new ideas because eventually we can help a lot of the patients. And this is a great example, even though it's not always pleasant, what a win to be able to cut something out of your diet and be totally symptom free.
Jennifer Fugo (25:15.167)
Well, thank you so much for sharing your experience and expertise with us once again. And you do see patients in the Chicago area. So I know that you always have people flying in from all different places to come see you, but it was such a pleasure to watch you in action. I've seen you at conventions, meeting with patients, talking with other doctors and practitioners. I just love, you always are so present and so giving, and I just love that about you. There's like such an open-mindedness. I know your patients, the thing that resonated with me most was how deeply appreciative they were for how you listen to them. And that's why I know everyone in this audience loves hearing from you. So thank you so much for sharing this information with us.
Peter Lio (26:09.654)
My pleasure and thank you for the kind words. We'll do this again soon sometime, I hope.
Jennifer Fugo (26:13.383)
Absolutely.
