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Did you know that the severity of eczema symptoms + skin color have a unique relationship? That certain eczema symptoms can be WORSE for skin of color versus white or lighter skin tones?
While practitioners are typically taught about the “classic eczema patient” who has itchy eczema, there is huge variation in how atopic dermatitis (eczema) manifests on different skin tones.
Eczema on black skin, for instance, often presents as itchy skin bumps in areas not usually associated with atopic dermatitis.
One main metric used to diagnose eczema is redness. But inflammation and eczema on dark skin often show up purple or grey, which makes it tough for practitioners to diagnose — especially if they were only taught to look for redness.
So today, let’s dive into the complex topic of eczema symptoms + skin color thanks to NEW RESEARCH from returning guest – Dr. Shawn Kwatra!
We talk about why people of color so often struggle to get a correct skin rash diagnosis (black skin versus asian skin versus white skin), different ways chronic skin rashes manifest in different races, and much more!
This topic is of particular importance because rashes (depending on race) can present looking more like psoriasis when it’s actually eczema – thus leading to misdiagnosis. Plus we’re discussing how to measure how itchy you are (no matter your skin tone) so you can convey it accurately to your doctor.
Shawn Kwatra, MD, is a Director of the Johns Hopkins Itch Center and an Associate Professor of Dermatology at the Johns Hopkins University School of Medicine in Baltimore, MD, USA.
He specializes in medical dermatology areas of clinical expertise, including atopic dermatitis, psoriasis, chronic itch of unknown origin and dermatology for ethnic skin. Dr. Kwatra also runs a basic science laboratory and clinical trials unit and is funded by the National Institutes of Health and multiple foundations.
Dr. Kwatra has been an author or co-author on over 200 publications and author of the book Living with Itch.
This was such a fascinating conversation and I am so excited to share it with you!
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In This Episode:
- Eczema symptoms-skin tone connection: How rashes look different based on skin color
- Why eczema symptoms can be mistaken for psoriasis
- Importance of serum IgE lab test for eczema
- Who is MOST affected by Prurigo Nodularis?
- Why topical steroids create eczema white patches on skin
- Non-steroidal medication options for eczema symptoms
- How skin of color patients lose out on getting better treatment options
- BEST way to show your dermatologist how itchy you are
Quotes
“If you have atopic dermatitis and you are a skin of color patient, and particularly an African American patient, you're more likely to develop these small bumps for your eczema or prurigo nodules.”
“If you apply a topical steroid for a long time, your skin actually gets lighter. And sometimes it takes many months to years to go back, and sometimes it can actually even be permanent. So we have to be really careful in skin of color patients when we're giving topical steroids, of the potency, and the duration of use, even on the scalp.”
Links
Find Dr. Shawn Kwatra online here and here | Twitter
Get Dr. Kwatra's book Living with Itch: A Patient's Guide
Diagnosing Atopic Dermatitis in Skin of Color (Dr. Kwatra’s paper)
331: Eczema Symptoms-Skin Color Connection: Why Skin Tone May Make Certain Symptoms WORSE {FULL TRANSCRIPT}
Jennifer Fugo (00:08.425)
Dr. Kwatra, welcome back to the show!
Dr. Shawn Kwatra (00:11.65)
Thank you so much for having me, Jen.
Jennifer Fugo (00:14.168)
I'm excited because the two episodes that we have done so far have gotten a lot of great feedback. And so I felt like, since especially you've had a plethora of research come out this year, that there were some other really great topics that we could talk about here that hold space for conditions or for different groups of people that might not feel seen in some of these conversations on itch. And specifically in this conversation, I wanted to talk about skin of color and how it can vary, the condition and the severity of the symptoms and whatnot can vary for those with skin of color. Whereas, you know, I've had clients, admittedly, who've really struggled, especially those with eczema on black skin, have had a really hard time getting diagnosed very clearly. And it looks like from this paper that you published, some really interesting differences… that inflammation can present differently in different skin tones and can increase eczema symptoms. And so, could you share with us why a study like this is so important?
Dr. Shawn Kwatra (01:28.458)
Absolutely, Jen. So, you know, I see a wide variety and diversity of patients. And one thing that we've noted is, in patients who have atopic dermatitis, the eczema symptoms look and present extremely differently. So sometimes, you know, we have the classical eczema patient who has these itchy skin areas in their antecubital fossa, so in the elbows, behind the knees. And that's how we were classically taught. There's actually a criteria, it's called the Hanifin and Rajka criteria for atopic dermatitis and it talks about that. Well, it has to be in these flexural areas and other things like that. What we found is that there actually is a tremendous amount of diversity in terms of the way the disease presents.
So, for example, skin of color patients, particularly patients with eczema on black patients on skin, can oftentimes present with small bumps. So especially kids with eczema symptoms, they come in and they have a lot of these small bumps, say on their trunk. And they're around the hair follicle oftentimes, so follicularly based. They're very itchy. But it's not necessarily what you expect, flexural areas in the creases of the elbows and behind the knees, there a're these small bumps. And as folks get older, we also see that the lesions of eczema can be in extensor areas. So they can be on the outer hands, on the outer aspect, extensor aspect of the arms, areas that may not typically be associated with atopic dermatitis.
So then if you think about other distinct features, We also found that folks are more likely to have a depigmentation. If you're a skin of color patient, that's a pretty unique morbidity of having active lesions of eczema, is that once the eczema goes away, you could be left with this dark spot for months, sometimes years, sometimes even permanently, and sometimes it's depigmentation. So it can be a pink color or a light color, and that can really cause a lot of disturbances for folks. And I'd say one of the main metrics we use to evaluate the degree of severity of eczema symptoms is how red it is or how erythematous it is. And actually in a lot of skin of color patients, it becomes more difficult to actually assess their skin because you can't appreciate that same level of redness. It may appear more purple, more dusky. In a patient who has a darker skin tone, you may not even know that they're having a lot of redness or inflammation. So it can make things very difficult and also challenging for providers. And for patients, oftentimes patients can have their care delayed and come in with more severe presentations of disease as well.
Jennifer Fugo (04:26.74)
So with some of these groups that you looked at, I found a lot of really interesting observations that you made with different specific groups of basically how, even just the presentation was different or there was certain aspects of genetics or how their immune system responded that were different. Can you talk a little bit about that? I think it's helpful for people to know that perhaps their condition might be, you know, like it's okay to feel like this seems different than somebody else's. And perhaps understanding how there might be a slightly different presentation could help them maybe get help sooner.
Dr. Shawn Kwatra (05:15.05)
Absolutely. So we've actually been studying, in-depth, black eczema skin as well. And one thing we found is that there's decreased ceramides, and others have found this actually, it's been documented, that there's been decreased ceramides and actually increased transepidermal water loss. So a propensity towards having drier skin. There can also be a lower pH of the stratum corneum, and that's associated with skin integrity and epidermal lipid content. So that's very important for your skin.
Also, there's been some suggestions of a larger mast cell size. And the mast cells are very important because they release these granules that then mediate itch. So that's also been found to be different. One other difference that has been noted is that there seem to be different genetics underlying the condition. Filaggrin mutations may be more common in Caucasian patients and less common in other groups. Asian patients actually oftentimes have more scaling lesions also, actually even sometimes looking psoriasis-like. So that's really important because actually if a dermatologist or another provider does a biopsy of your eczema, it can actually come back saying it's psoriasis, but it's really eczema.
Jennifer Fugo (06:35.124)
Wow, so how would you differentiate, then, between the two?
Dr. Shawn Kwatra (06:39.442)
It's very complicated. So actually recently I had a patient I was taking care of and they'd been treated with many of these psoriasis biologics. I'm sure you've heard of many of them, IL-17 inhibitors, IL-23 inhibitors, and they failed to respond. Biopsy said psoriasiform dermatitis, but we looked at these patients and found that they actually had many minor signs of atopic dermatitis too. So this is where a lot of the diagnostician elements come in.
So one of the things that's unique about eczema patients is that they oftentimes have hyperlinear palms, so more lines on their palms, I know I do as well, or thickened palms. So I'll just go ahead and show my own hand. I've been told I have very manly hands, which I love hearing, but it's actually because I'm more atopic. So I have asthma and eczema, I've had seasonal allergies growing up too. I have very tough palms and I have a lot of lines on my hands also. So when you're evaluating a patient, if you see some of these minor signs as well, that can help push you in the right direction.
Other minor signs, so folks oftentimes have something called the infra-auricular fissure, which is a study that we had done previously actually behind the ears. There's some areas that tend to be affected. There's also a Dennie-Morgan line, which is an extra line under the eyes, the infraorbital fold, that's very common in folks who have eczema or atopy because they're oftentimes rubbing their eyes because of allergy. So that's another very common symptom that you have. You look for dry skin, sometimes referred to as ichthyosis. So that very dry plate-like scale in many ways. And then there's many other features. So we look in the neck folds, and oftentimes there's an area called the dirty neck. I know I had it and sometimes have it, that area tends to be affected a lot.
Jennifer Fugo (08:40.864)
Can I also ask you too about serum IgE levels? I noticed that you had noted in the paper along with the other, I guess the co-authors, that there tended to be a higher serum IgE level. Could you talk a little bit about what that is and why that might be clinically significant and if it's important for doctors and dermatologists to run that?
Dr. Shawn Kwatra (09:09.482)
Absolutely. So there's some debate how important an IgE level is. So let me put this into context. IgE is actually a marker of allergy, of inflammation, and one thing we found is that IgE is actually also associated with what we refer to as type 2 inflammation. So if you were to give someone, for example, dupilumab therapy, if they have a high IgE, then that drug would also lower the IgE and work on those patients. And so when I'm not sure what's going on, oftentimes you can get an IgE level. So the wrinkle is that there's another condition, hives or urticaria, as well, that also is characterized by these very high IgE levels. So there's been some confusion. Some folks think, oh, a high IgE, that means you have hives.
But what we're finding now is, when I'm treating undifferentiated itch patients in general, we're trying to get a sense, what type of inflammation do they have? Is it more immune-mediated? And I use the term type 2 inflammation. So that's certain cytokines, IL-4 and 13, IL-31 also, they all fall within this category of type 2 inflammation. So now what we're finding is that folks who have itch and we're not sure what type they have, if they have a high IgE level or actually a high level of eosinophils, which can come on a complete blood count when you do differential, that's a good marker. They'll respond to immune modulator therapies. Things like dupilumab therapy or tralokinumab, which is another biologic. Prednisone, although we hate using prednisone, or methotrexate or other immune-modifying medications. So folks who have more uncontrolled disease oftentimes have a higher IgE, so it can also be a marker of uncontrolled disease, which is why sometimes you may see higher IgE levels.
Dr. Shawn Kwatra (11:09.93)
To me, an IgE can be helpful though, if you don't know why the itch is happening, sometimes it can point you towards the right direction in terms of therapies that we need to try. And those blood eosinophils, so in that patient I had talked to you about who had a form of eczema that looked very much so like psoriasis, they actually had very high blood eosinophil levels, which was a marker to me that their immune system was tilted towards more of what we call type 2 inflammation. And then they got better with treatment for their eczema symptoms, actually with dupilumab therapy. They got better, even though they had failed many psoriasis-like therapies.
So that's kind of a nuance. And what we're doing is we're studying the blood a lot more because a lot of these itch conditions actually are featuring inflammation in your blood. So higher C-reactive protein levels, bloody eosinophil levels, IgE. We're seeing a lot of these are higher in skin of color patients, but that may just be that their actual underlying disease is being delayed appropriate therapy as well, and they're coming with a more severe disease presentation also because of poor recognition.
Jennifer Fugo (12:16.444)
And I think it would be fair to also mention, because we did do a previous episode on prurigo nodularis, that you mentioned that here as well, that it could be being confused possibly for atopic dermatitis and that it does disproportionately affect skin of color. Do you want to just talk a little bit about that? And then obviously we can link up to that other episode for a full deep dive.
Dr. Shawn Kwatra (12:40.174)
Sure. So if you have atopic dermatitis and you are a skin of color patient, and particularly an African American patient, you're more likely to develop these small bumps for your eczema or prurigo nodules. So those are just itchy skin bumps. They can be anywhere on your skin because there's a greater propensity towards having skin thickening, fibrosis, a lot of those different features, in black patients. We know there's higher rates of scleroderma, so systemic diseases that are characterized by fibrosis, as well. There's more scarring disorders, even hair loss, scarring hair loss, keloids, which are very thickened. So if you have atopic dermatitis, you're more likely, if you're a skin of color patient, particularly African American, to have accompanying prurigo nodularis, so classical eczema areas and these raised itchy skin bumps.
You're also more likely to have just prurigo nodularis alone, which tends to develop in middle age. So we actually performed the first genetic study to actually calculate and create a polygenic risk score, finding that some folks are actually predisposed to developing these itchy skin bumps or nodules. And they're more likely to be African and Asian ancestry as well. So in the United States, what we found is that you're actually 3.4 times more likely, black patients are, to develop prurigo nodularis and it's more common in Asians as well. So we think that's a combination of genetic and environmental factors.
Jennifer Fugo (14:15.264)
Yeah, and I think also raising awareness about it so that way too, sometimes you can go and just say, hey, I know that you don't like me going on Google, but I did come across this condition. I would imagine if maybe a dermatologist hasn't seen something like prurigo nodularis frequently, that could be something that they might not even have thought of or considered. And so I always think it can be sometimes helpful to bring some ideas to the table, it’s a worthwhile question to consider.
I did want to ask you, so something jumped out at me when I was reading this paper and you talked about, and you mentioned it already, about this depigmentation. So how does eczema white patches on skin happen in regards to topical steroids? Because you mentioned them specifically in this section. So what is, maybe talk a little bit about the different presentations of depigmentation that can show up. And then how does this happen that this stuff, which unfortunately, topical steroids tend to be, it seems like the first thing that we're getting. I mean, that was the first thing I was prescribed when I had dyshidrotic eczema, it's like the first line of defense basically. So how can they play a role in, I guess, creating this depigmentation?
Dr. Shawn Kwatra (15:35.198)
Absolutely. So I think we are relying way too much on topical steroids, and they've actually been grandfathered in, their approvals, all you have to do is more of a vasoconstrictive assay to get these drugs approved, but they haven't gone through our formal clinical trials. And I think because of that, we sometimes do a disservice because we aren't counseling properly about the many and significant side effects of topical steroids. So prolonged topical steroid use is not something that we want. Chiefly, we're worried about atrophy or thinning of the skin. So that can happen if folks have been using this topical steroid continuously. Definitely more common with more potent steroids, so things like clobetazole or the fluocinonide. So those are class I and class II types of topical steroids.
And also, especially in skin of color patients, there's this very unique side effect of this, depigmentation and eczema white patches on skin. So if you apply a topical steroid for a long time, your skin actually gets lighter. And sometimes it takes many months to years to go back, and sometimes it can actually even be permanent. So we have to be really careful in skin of color patients when we're giving topical steroids, of the potency, and the duration of use, even on the scalp. Folks have used oils, scalp oils, and I've seen the scalp get lighter. So I actually have relied a lot more on non-steroidal medications. So there's actually a bunch of non-steroidal medications for eczema symptoms that are approved, you have topical crisaborole, it's a non-steroidal, you have the topical calcineurin inhibitors as well, tacrolimus and pimecrolimus. And then you have also some newer generation agents that are about to be approved in phase three. One of them is topical roflumilast, phosphodiesterase-4 inhibitor, and also another medicine, topical tapinarof. So I actually believe we are shifting. We should be shifting away from topical steroids which can cause eczema white patches on skin. These drugs were grandfathered in, they have a lot of risks. And actually that burden of side effects is even more so heightened in skin and color patients with the depigmentation. And so I think we're gonna be shifting more to these novel therapeutic agents.
The other issue is when folks have deeper nodules, so say in prurigo nodularis, you wanna inject some of these nodules sometimes with steroid, you gotta be really careful you get it only in that nodule, because if you inject a steroid into normal appearing skin, you can get hypopigmentation. I've actually seen many patients have their wrists injected for carpal tunnel or had some type of steroid injection and then you can see the whole area just be dispigmented and white throughout. So that's why I don't think people are counseling enough on topical steroids and I actually think we need to have a big movement to help make sure that we're putting proper guardrails and we're also making it easier to use many of these safer topical non-steroidal agents that are becoming available. It's really important that we highlight the risks of topical steroids.
Jennifer Fugo (18:53.264)
I agree because you and I both know a lot of individuals who had decades of exposure to these products and really it can cause harm to some individuals and it's not to say that, I think in general, we need a systemic change, essentially.
Dr. Shawn Kwatra (19:11.222)
And I think it's a big problem because we're all very familiar using topical steroids because it's the easiest thing to get. It's cheap, we're used to it in our training programs, and so we give these drugs and we think they're okay, but if one of those drugs actually was going through these pipelines right now for approval that is so actually extensive and difficult to go through, there would be a lot of side effects emerging like this eczema white patches on skin. I think there'd be greater awareness on it. So I totally agree with you. We need to make sure there's a bigger movement here and make the other drugs, the topical non-steroidal drugs, easier to get. Right now to get a topical non-steroidal for some insurances, they say you have to try a topical steroid first and fail it, and then go to it. And I just question why. There's so many side effects of topical steroids. Why do we have to jump through a safer medicine?
Jennifer Fugo (20:04.508)
And too, they're oftentimes used for itch, which is obviously something you and I have talked extensively about. I feel like you're like the king of itch. Because you study it so much in your lab. We talked about it extensively in Episode 275: Why Are You So Itchy? And then this study, you also looked at itch as a possible differentiator in how people experience their condition based on different skin colors or skin tones. So what did you find?
Dr. Shawn Kwatra (20:39.602)
Yeah, absolutely. So we've done a lot of studies on itch and skin of color patients. And the first thing was, what are the conditions that it's more common in? So atopic dermatitis, prurigo nodularis, those are common conditions. When we've actually also done studies, we found that actually in many African American patients, they have very high itch intensities too. But there's a mismatch. So one of our studies found that actually skin of color patients are less likely to get many of our advanced and novel therapeutics, even though they have more itch. So what we're trying to tease out is, is it biologically folks have a propensity towards more itch, or is it more so that there's poor disease recognition and a delay in therapy?
And so that's why one of the things that I've been truly advocating for is to use itch and the concept of itch as a bedside tool. It's a sensor. So don't trust your eyes, right? Your eyes are looking at someone and they're saying, okay, well, I don't see a lot of redness, their disease must be, you know, under control and not that bad. No. What I do now is I double check myself for bias and I ask folks, how severe is your itch? And I use a tool. It's called the WI-NRS or the Worst Itch Numeric Rating Scale. So all you have to ask someone is, what's the worst itch you had in the last 24 hours? Where zero is nothing and 10 is the worst itch. And I can't tell you how many times I've been surprised. So I'm looking at someone's eczema symptoms and I'm saying, oh, they're gonna say they probably had maybe a two or three and they tell me an eight or a nine. And I do a double take. And when our lab has done research into even the normal appearing skin and eczema, we found that it has more inflammation than a healthy patient.
And in eczema on black skin or in an Asian patient, oftentimes you cannot appreciate that redness. So what we're advocating for is that itch is a realtime marker or sensor of disease severity. And our other work has shown that folks who have itch are more likely to have systemic inflammation, so increased C-reactive protein levels, and also the onset of new comorbidities. So I'm using itch now as a realtime sensor. I'm asking patients to keep diaries.
Dr. Shawn Kwatra (22:54.402)
We're looking at it and even if their disease doesn't look that bad, if they have a high itch, that's really a marker for me of up titrating therapy. There's a movement going on in atopic dermatitis to identify a new subtype also of eczema called itch-dominant eczema or itch-dominant atopic dermatitis. These are the patients who are suffering from really debilitating itch but it doesn't look like they have a lot of lesions.
And so I think we're gonna hear more about this in the future, that group of patient populations that has been suffering and using itch as that sensor. That's what I'm encouraging everyone to do right now is ask their patients, just zero to 10, what's the worst itch you had in the last 24 hours? If someone's seven or above, that's severe. You should be thinking about a systemic therapy. You should be thinking about what am I going to do? I'm going to follow up quickly with this patient. If they're not better, we have to really try to address this because if they're itching, they're not sleeping. If they're not sleeping, they're having dramatic problems with their mood, their work productivity, overall quality of life. It's super disrupted. And when we looked at the overall quality of life impact, it's similar to stroke, heart failure, folks on hemodialysis. That's the level of morbidity we're talking about.
Jennifer Fugo (24:09.248)
And it sounds like this is something that listeners could actually do at home, as you said, on that scale from one to 10, maybe keep a diary, as you suggested. So is this something that, like, what would you counsel a patient on? Is it something you do once a day? Is it something that they should do different times of the day? Because sometimes we can, I've noticed clients will get itchier, say, at night, as opposed to during the day. So what would you suggest somebody do so that they could possibly bring this to their dermatologist?
Dr. Shawn Kwatra (24:40.158)
Absolutely. So it's a wonderful question, I totally agree with you. I think it's a way folks can empower themselves because now some of these drugs are getting approved with this, it's called Worst Itch Numeric Rating Scale or Peak Pruritus Numerical Rating Scale. But basically what it is is, zero is no itch at all whatsoever, ten is the is the worst itch imaginable. And what you're looking at is in the last 24 hours. You can do it in the morning or the night because you're gonna capture a 24-hour period. And you look back, okay, in the last 24 hours, at any point, what's the worst itch I've experienced? And I think that can very much so help you be able to go into your doctor and say, okay, you think my skin may not look severe. My itch is a seven, eight, a nine out of 10, and the topicals aren't working. So I would like to discuss systemic options because the itch, as we know, can cause lots of problems with sleep and my quality of life and my work, the disturbance, and all of those different things. So it's a way to truly empower patients. I think it's a great idea.
Jennifer Fugo (25:50.944)
I think it's a great idea too, because it's free, it's a free tool, but it also provides more information. And as you said, you then can go sit and have a conversation about not just like, oh, here's how my skin looks today. You can say, look, I kept a log and over the last three weeks, this is what's been going on. And that should be something that hopefully their dermatologist should be able to translate into something a little more actionable for them. That would be my hope instead of just saying, here's a higher potency steroid, I'll see you in two weeks or whatever it is. Because I eould assume there's a point where like you said, there's risks to just the topical steroids. I will acknowledge that I have interviewed so many derms and several allergists at this point that antihistamines don't always help, and you even shared that sometimes the antihistamines don't help.
Dr. Shawn Kwatra (26:45.554)
Most of the time they don't help, yeah.
Jennifer Fugo (26:48.304)
So at that point, this might be a helpful talking point to help them advocate for themselves. So I think it's a great, I think this is great that we had this conversation.
Dr. Shawn Kwatra (26:57.402)
And the reason now is the right time that we're having this conversation is because we are in the midst of a translational revolution in itch, because there's so many new therapeutics that have just been approved or recently approved or are becoming approved in the future. And so there's never been a better time for patients to get very targeted, safe, and rapidly acting therapies to help their itch. So now what we need folks to do is we need them to advocate for their own care, right? We don't want you to just be delayed because unfortunately what's happened is many dermatologists have, in their training somewhere or another, got the message that you should just look at the skin and let that tell you the story. And if you see a big rash, then you know how to treat it. Somewhere that message got through to many dermatologists, unfortunately. And asking about your itch is the way that you can factor in the patient voice, the symptoms, patient experience. Because you're actually not getting morbidity from your rash as much as you're getting morbidity from the symptoms and from the itch.
So it's actually turning the tables on this impression that it's actually the rash that's most important. No, it's the symptoms, it's the itch. And let the patient say what's most important. That's the thing that bothers me the most, is that when folks don't ask about the itch and they just look at someone and say, okay, here's your therapy, but how do we know how much it's affecting that person? And when we have studies showing that normal appearing skin is where a lot of the itch occurs, and there's actually, amount of itch that you have directly correlates with the amount of inflammation also that you're experiencing and in the bloodstream. So we have to take itch very seriously. And so I'm very hopeful that patients will advocate for themselves and that'll help them get on the right therapeutics that they need. And I think this revolution going on with new therapeutics is gonna help spearhead this development.
Jennifer Fugo (28:58.888)
I just want to thank you so much for talking about this because I think a lot of listeners are going to feel very seen and heard. And I appreciate you for all of the research you do. I love that you are so curious about this. I feel like this is the cross you decided to pick up, and you are changing the way that people think about it. And that translates. I mean, just the comments alone and emails that I have gotten about our episodes and the things that you have shared has really transformed people's lives. Where at the least they're like, oh my gosh, for the first time, I feel like somebody is talking about me and understands the suffering that I'm going through. And so I just want to thank you so much for coming back again. I'm sure you'll be back again on the show. But thank you so much for being here.
Dr. Shawn Kwatra (29:57.27)
Thank you so much for having me. And what I'll say is that there's a lot of fuel and drive and energy that comes for advocating for patients in a patient population that's been forgotten for so long and has been suffering and quiet, and advocating for them really gives me a lot of purpose and energy. So that's really where it all comes from, is being able to be an advocate for folks. So I use any platform in any way we can to kind of amplify what folks are going through and what we can do to help them. So thank you too, Jen, because your show is a great platform for advancing care for patients.
