220: The Gut Microbiome Of Acne [NEW RESEARCH] w/ Dr. Julie Greenberg

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If you are struggling with adult acne, today's episode is for you! This episode is celebrating new published research by Dr. Julie Greenberg on the make-up of the gut microbiome of someone whose primary complaint is acne!

These findings can help us all better know what steps can be taken to support someone struggling with acne, but it also underscores that other skin issues (like eczema) may have a very different gut microbiome diversity. Time will tell as that research eventually becomes available.

For now, let's dive into the distinct gut microbiome that tends to show up in acne!

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

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

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

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

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

Join us as we discuss some exciting new research into the gut microbiome and acne.

Has working on your gut health improved your acne? Let me know in the comments!

In this episode:

  • How prevalent of a problem is acne?
  • Why does acne occur?
  • The difference between a trigger and a root cause
  • Three things that typify the acne gut based on her published research
  • How much fiber do you REALLY need to eat to help with acne?
  • The problem with eating too much meat
  • Why dairy can be problematic for acne


“Acne occurs within a hair follicle. Every acne zit or pimple that is one somebody's face, chest, back, is happening in a hair follicle.” [3:22]

“What I found was three things that kind of typify the acne gut. One is H Pylori (Helicobacter pylori)  is present. One is candida. Candida is elevated or high. And the third thing is protozoa.” [11:46]


Find Dr. Greenberg online

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

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

Dr. Greenberg's research on acne and the gut

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

220: The Gut Microbiome Of Acne [NEW RESEARCH] w/ Dr. Julie Greenberg FULL TRANSCRIPT

Jennifer: Dr. Greenberg, thank you so much for being back here on the show. As always, you're one of my favorite guests. Every time you come on the show, I feel like some of the guests, you're one of them, Kiran] is one of those people where I feel like my brain just explodes with all the wisdom he provides and you are the same way. Every time, every episode that you've shared here on the show, I learn so much from you. So thank you so much for being here to talk about acne. We were having an interesting conversation before we started about, as teenagers, I mean, I was one. I was a teenager who had acne. We have a lot of teenagers that get acne. But then we're seeing this reemergence later in life. A lot of women, even post menopausal women are now getting acne. So what are the stats that you're seeing, that you're looking at in research that helps us better understand how prevalent of a problem is acne?

Dr. Greenberg: Yeah, it's a great point. And when I was growing up, my generation, acne was really a teenage problem. I mean, really for the most part, unless someone had just a horrible family history. It was like, “Oh, you're going to grow out of acne,” and that was primarily true. And today, it's still a huge problem in teens. About 80% to 90% of teens will still get acne, males a little bit higher percentages, more like 90%, females, a little bit more like 80%, just because obviously they're going through puberty and males have a little bit, or a lot more testosterone going on. We know testosterone drives sebum production.

Dr. Greenberg: But the numbers for adults are really pretty staggering. And I would say in my practice, I probably even see more adults than teens now for acne, and it's one of the top two conditions I treat. Eczema and acne are my top two. In adults, it's 65% of menstruating females will report monthly outbreaks of acne, often related to the timing of their cycle. Most commonly is one to two weeks prior to menstruation. That's going to be a little bit correlated with ovulation. But it's not just women. It's men and women in their 20s, 30s and 40s. Up to half are reporting this kind of low grade chronic acne. And as you said, even up to 25% of females in their 40s are still reporting acne. And then I do have male and female patients who are beyond those, kind of in the 50s and 60s who are still struggling with acne. So it is very much an adult problem now and really not just a teenage thing at all. It's pretty ubiquitous.

Jennifer: So what do you think is one of the missing pieces in how we look at acne? Because all the ads on TV would make you believe that it's what you put on your skin. And I do agree that's a piece of the puzzle. But what does acne, when you see a patient come through your door, who their primary complaint is acne, what are some of the key areas that you look at, that they may not have heard before? I mean, obviously, I know you're going to mention the gut. I think everybody here knows you're going to mention the gut. But I know that you've done specific research we're going to talk about today that is going to help maybe clarify for people how to think about acne in a different way.

Dr. Greenberg: Yeah. So I think the first thing to realize that a lot of people don't is that acne occurs within a hair follicle. Every acne zit or pimple that is one somebody's face, chest, back, is happening in a hair follicle. And it starts with a gland called a sebocyte. And a sebocyte produces sebum. And if your listeners have never heard of sebum, it's a lipid or an oil that's produced in the hair follicle. Sebum is good. It helps that hair. Hair has to come break through the skin. It has to come up and out of the follicle, break through the skin. Sebum helps it do that and not get stuck. And sebum also comes out and moisturizes the face and scalp, so sebum is good. This is not a bad thing.

Dr. Greenberg: But just like anything, it's a Goldilocks. We don't want too much. We don't want too little. And acne is a problem of too much sebum production. That's step one in what we call the pathophysiology, or what's going wrong in the hair follicle. So we get too much sebum production. There can be too much skin cell production going on in that follicle. The hair follicle becomes trapped, and then we can often get a buildup of either bacteria, which can be cutibacterium acnes. It used to be called propionibacterium acnes. That's the same bacteria.

Dr. Greenberg: Or it can be fungal acne due to a yeast that is found on the skin called Malassezia. Malassezia on the skin up at the top is fine, but sometimes it dives down into that follicle and gets trapped. And then we get this immune response, this pus, and this big inflammation response, which is basically acne. So that's the first thing to realize is that it is happening in a hair follicle, and it happens in sebum rich areas. So no one gets acne on the front of their shin. That's not acne. Acne happens on the face, neck, chest and back. These are areas where we have naturally high levels of sebum production, so that's kind of the set up.

Dr. Greenberg: And to your point, I mean, I think there's a lot out there in terms of what are triggers for acne. And I always break down for patients, there's a difference between a trigger and a root cause. A trigger is something that can make your condition worse for sure. But if we take that trigger away, we ask, “Does the condition heal? Is it gone?” And if the answer is no, then it's still not the root cause. I mean, it's playing a role. But if it was really a root cause, we take it away and the problem is over. So that's I think what makes acne so complicated, is there are so many potential triggers for acne, things that can make it worse. I mean, one thing that's specific to COVID is we have a whole new thing called maskne. Right? We never had this before because we weren't really wearing masks like this. Lots of people are breaking out under their mask. It's a real thing, and so that's potentially a trigger.

Dr. Greenberg: Our whole food that we're eating in our Western society, there's a whole thing we can talk about, how food can drive acne, certainly a trigger. Hormones are involved in the production of acne because they can drive sebum production. But ultimately, for me I've found you really do have to go to the gut. I test and treat the gut. And there's a very particular profile I see in my acne patients of dysbiosis. Dysbiosis means things that are going wrong in the gut, too many bad guys, too little good guys, and it's really specific to my acne patients and a very different picture than let's say what I'll see in my eczema patients. I can actually tell from looking at the labs this is an eczema patient, or no, this is going to be an acne patient.

Jennifer: That's really interesting. So this may be a good also kind of guideline for someone who's dealing with acne. I don't work with acne cases. I work with eczema and psoriasis. And that's an interesting point, so perhaps if someone was to say that to you, this is the type of skin issue I work with, but not acne, which is your main concern, it might behoove you to actually look for somebody who is looking at this type of lab work, like yourself, where you really understand that particular pattern, and you can see it and spot issues that I'm just not used to seeing because it's not my focus.

Dr. Greenberg: Yeah. Yeah. And I mean, fortunately, it's actually not that complicated a pattern in acne. So once you know what to look for, for me, I do two tests. And if your listeners have listened to any of my podcasts with you, they'll know I do a stool test, so that is a poop test. Patients poop into a tray and get to collect their stool. Good times for about five minutes. But what's really helpful about it is we get a good look at the bacterial profile in there. And then I do a second test called an organic acid test, or OAT for short. It's a urine test. And the reason I like to do that one is it really helps round out the fungal element like candida. The stool test doesn't always pick up the fungal elements as well, I find, as the OAT.

Dr. Greenberg: And yeah, so it's been interesting because I've published research on the findings of the gut microbiome of my acne patients. And it's really been interesting not just to the integrative and functional medicine world, but it's being published in a conventional dermatology journal next month. And we have things called medical posters at conferences, and it was displayed at a conventional dermatology conference just earlier this month. So conventional dermatologists are starting to take note and realize there is a bigger piece than just slapping something on the skin. And maybe the gut has something to do with it.

Jennifer: Well, first of all, congratulations. It is big deal and a huge honor to get published, and then to be able to showcase your work at these medical conferences, especially on that is more on the conventional side because you're introducing things that do kind of go against the grain, which is awesome. And I'm sure the listeners here who've listened to your other episodes can really appreciate the work that you're doing in pushing the boundaries because that's a lot of our complaint is, hey, there's other things going on. How can we start to get this into that more mainstream thought pattern? And you are actively doing that, which is awesome.

Jennifer: So would you … A, I'm going to share your journal link, so if people are interested, and practitioners who are listening to the show, they can go and check it out. But would you mind talking through some of your findings to help listeners understand what … And again, this isn't … I don't think anyone should say, “Well, Dr. Greenberg said that an acne pattern looks like this, so this is what's going on with me. And I don't need to get this testing done.” Obviously, there's variations. But generally speaking, what are you seeing?

Dr. Greenberg: Yeah. So that's a good point, and I'll take you through what I'm seeing and what the prevalence is or how many people tend to fall into which patterns. But that is correct, and I talk to patients before we test and I say, “Okay, look. I can see that you have acne. I'm guessing at what's going on.” But this is individualized medicine. And there's probably other things going on outside of that, and so I do recommend that each individual patient do testing and work with a licensed and knowledgeable practitioner because there's usually more to the puzzle than just what I'm going to talk about. And having the full picture is really helpful in terms of really being able to clean it up and clean it up in a timely manner, so that's a good point.

Dr. Greenberg: Yeah, so the big reveal, so the way I did it is we have something called diagnosis codes as doctors. And I pulled from my database at The Center for Integrative Dermatology, the 36 most recent patients who have a diagnosis of acne. And then I pulled their stool tests and their OAT urine test to analyze what the findings were. Now I did this by hand. And then another company called Biocanic, that's a software company that can analyze functional medicine tests, also did their own analysis. I went in specifically thinking I was going to see three things, but I wanted to make sure I wasn't missing anything. So Biocanic did a bigger analysis to see beyond these three things. Were there any other similarities happening in the gut microbiome of the acne patients?

Dr. Greenberg: So again, I looked at these 36 patients, and what I found was three things that kind of typify the acne gut. One is H Pylori, Helicobacter pylori is present. One is candida. Candida is elevated or high. And the third thing is protozoa. And protozoa are little single celled kind of animal organisms. And the breakdown was 94% of patients that I looked at had elevated or high candida. 92% of patients had present or high H Pylori, Helicobacter pylori, and 53% of patients had protozoa of some kind. So there's many different types of protozoa. There's more pathogenic ones like Giardia. There's other ones like Blastocystis hominis or Endolimax nana that some practitioners are like, “Oh, it's not a big deal. Just leave it alone.” I treat anything.

Jennifer: I've heard that I can't even tell you how many times I've referred a client back to a doctor, and I said, “Look, they have Endolimax nana.” Oh, no, no, just leave it. It's fine. It doesn't do anything. And I'm like, “But they have all these symptoms.” So what you're saying to anybody who's listening, if you are a practitioner, if you see that show up and the patient or client has symptoms, it may actually behoove you to take action on that.

Dr. Greenberg: Yeah. And I will treat it. And it's the same with H Pylori. Some people, practitioners are like, “Well, if it's not high, I'm going to leave it alone.” Nope, I am going to treat it. So in terms then, so those were the breakdowns and the percentages. In terms of: Well, how many people had each thing? So 47% of those patients, or 17, had all three conditions, so almost half, yeah, it was a pretty good profile. About 44% had two, and generally those two was the H Pylori and the candida if they only had two. The protozoa and the … So 91% of my cohort had all three or two of these conditions. And again, this is really different than what I see in my eczema patients or any of my other patients, alopecia areata, psoriasis. This is an acne picture.

Dr. Greenberg: The protozoa is really intimately tied to H Pylori. So if you were in that 53% who had H Pylor, almost all of them, 95 … Sorry, protozoa. So if you were in the half who had protozoa, almost all of them had H Pylori, 95%. And the reason is because H Pylori is a bacteria that lives in the stomach. And what we tend to see is that H Pylori gets in there and the way I tell it to patients is it's uncomfortable. It's really acidic. We didn't even think anything could live in the stomach. It's crazy that H Pylori is there. There was two doctors who proved that H Pylori caused ulcers. And before they proved it, they were called quacks. And then after they proved it, they received the Nobel Prize. But yeah, H Pylori absolutely gets in there, lives in there. We know that.

Dr. Greenberg: But it can often make changes to the stomach acid. And sometimes it lowers the stomach acid to create a more comfortable environment for it. And when we lower the stomach acid, it's a huge problem because stomach acid is there for a purpose. It's going to kill off things that we bring in through our mouth. And every time we swallow saliva, we swallow a liter, a liter and a half of saliva a day, every time we eat a bite of food or drink a beverage, we're bringing all sorts of crazy things down into our body, bacteria, viruses, molds, protozoa, critters. And by design, the first stop is the fiery acidic cauldron of our stomach acid. And they're supposed to kind of sizzle and die.

Dr. Greenberg: But when H Pylori is there and it monkeys with our stomach acid and it's not quite so acidic, if you get exposed to some protozoa, some of them may not die. And once they get out into the rest of the GI track, it's much easier for them to set up shop and have a little protozoa party in there. So that is what I see, and again, like you said, it's not 100%. And we still don't know exactly how all of these things come together to drive acne. I mean, that's a big question. And it's interesting because I found some research that showed that H Pylori in the stomach actually affects sebocyte and issues with … So this is a little scientific, but there's a growth pathway in the system called mTOR, and we know that's involved with acne. And then there's a mechanism in the cell called FOX01 that helps make sure that doesn't happen.

Dr. Greenberg: So in general, FOX01, I say is your friend if you have acne. There's something that we've seen in the stomach with H Pylori that H Pylori is inactivating FOX01. And when that happens, the sebocyte can kind of produce unfettered. And so we haven't seen direct relationships on outside of the stomach what H Pylori's doing, but I think there's an interesting idea there, and I'm hoping that research is done specifically on how H Pylori could be impacting the sebocyte in the face. And could it be through this inhibition of FOX01? And then the sebocytes just start cranking out sebum. So there's a lot we don't understand about how this sets up acne, but there's kind of a there or there.

Jennifer: Can I ask? Because I do get some questions about folliculitis. And obviously, it's not exactly the same, but you did mention that acne happens in a follicle.

Dr. Greenberg: Right.

Jennifer: Is it possible, and obviously, I know you didn't do your study around folliculitis, but is it possible that there could be similar factors at play in someone who is struggling with folliculitis similarly to acne?

Dr. Greenberg: Yeah. I think when it's on the face. So folliculitis is really an inflammation of the hair follicle. And it's fungal acne, or acne that's driven by Malassezia yeast is actually called and diagnosed as Malassezia folliculitis, so I think there's a lot of crossover. And folliculitis can be any kind of pathogen can be in there, so it can be a bacterial folliculitis, or it can be a fungal folliculitis. It's basically that this bacteria or fungus has dived down into the hair follicle where it's not supposed to be and it's causing inflammation. So there's a lot of crossover.

Dr. Greenberg: Now some people get folliculitis on their butt. They have sores and stuff like that. That's less I think of a typical acne profile where there's an overproduction of sebum involved because the tush is just not a high sebum producing area, so that may be just kind of a typical, we're not sure how, but a bacteria or a yeast element got down into the hair follicle. But when it is on the areas that are typical of acne, face, neck, chest and back, for me, I treat folliculitis and acne kind of the same. And I do think that there is kind of that underlying overproduction of sebum that's kicking it off.

Jennifer: Interesting. So you had mentioned in our conversation before we started recording how everyone assumes that their acne is hormonal. And obviously, we've discussed this is one clear example how it's not hormonal. Is there some way in which maybe hormonally triggered acne … Like you were saying, obviously there's patterns with the menstrual cycle, but a man is not going to have that issue, per se. So how could one differentiate a little bit if there is a hormonal component, or trigger, or root cause to what's going on as well?

Dr. Greenberg: Yeah. And that's a great question because pretty much every adult woman who comes to me, comes to me saying, “I have hormonal acne.” And it's like, “Well,” it's a little controversial, but I think that true kind of hormonal acne, meaning that a woman's systemic hormones are off, it's actually pretty rare. And you will see that in the literature. But let's talk about hormones and how it impacts acne. So we know, for example, that both insulin, which is a hormone, and testosterone will drive sebum production. So if you have high levels of insulin systemically or high levels of testosterone systemically, yeah, that is going to drive sebum production. And we keep coming back to that because that's step on in the kickoff of acne.

Dr. Greenberg: But there's two levels that we have to look at hormones when we're relating it to acne. There's systemically high levels. Are you cranking out too much testosterone in your whole body? And usually with women, that is only happening if they've been diagnosed with something like PCOS. Maybe then they actually have high levels of androgens like testosterone. But the other piece that's tricky is that the hair follicle has something called an androgen receptor. And if you're old like me and you remember a game called Hungry, Hungry Hippos.

Jennifer: Yes.

Dr. Greenberg: Where the hippos were trying to grab the balls in the center and you were going back and forth, you can think of an androgen receptor in the hair follicle like that. It's reaching up and grabbing testosterone from the bloodstream like, “Ooh, I need some testosterone.” Well, it's supposed to be operating at a normal level and pulling in an appropriate amount of testosterone. But it can become a hungry, hungry hippo for reasons we don't understand, and it will just start pulling in way too much testosterone. And the problem is not that someone has too much testosterone that's being produced in their system or is floating around their bloodstream. It's that one follicle, the androgen receptor, has gone bananas, and it's just pulling out too much testosterone or insulin from the bloodstream, which is then driving sebum production.

Dr. Greenberg: So I think we have to be careful to not to start to treat either with herbs or pharmaceuticals, levels of different hormones, at least without testing and knowing. And there are tests we can do for hormones. But I warn most of my female patients, look, we can go do this hormone testing, but it is likely going to come back normal. You're likely not, unless again, you have some other known problem like a PCOS, we're not going to find something in the blood. So I'm not going to treat you for systemic hormones. And I think what's really interesting is when we look at indigenous cultures. So by that I mean if you turn on a Nat Geo special and it's a tribe living in the Amazon, we've gone and studied these populations. And what we find is a dramatically different picture for acne for these people.

Dr. Greenberg: So we already talked about how 80% to 90% of teens and 65% of menstruating females, and half of men and women in the 20s, 30s and 40s, everyone in our society, really. I mean, do you know anybody who's never had a zit? I don't think there's such a thing.

Jennifer: No. It's touched everyone. Acne is a shared experience.

Dr. Greenberg: It is, right. Everyone gets it. But it's the opposite in indigenous cultures. And so researchers for example have gone and studied the Aché people in Paraguay. They live in the Amazon rainforest. It's a tribe of 115 people. Now it's a tribe, they've got men, women, menstruating females, teenagers. Research studied them over two and a half years looking at these 115 people, trying to figure out how much acne and what's going on. They couldn't even find a single zit, nothing, no acne in the whole tribe in two in a half years. In Okinawa, we've looked at that population prior to World War Two, and back then, this was a really remote island living population. Of course, Okinawa is at the southern tip of Japan. And they asked physicians who practiced there between eight and 40 years, “What's the prevalence of acne? How are you treating it?” And the physicians are like, “These people don't have any acne. We don't treat it.”

Dr. Greenberg: And we've looked at the Kitavan people in Papua, New Guinea, so they live in the rainforest. That's a tribe of about 1200 individuals, so lots of teens, lots of menstruating females, lots of hormones. 1200 people, they studied them for seven weeks. What do you think they found?

Jennifer: No acne.

Dr. Greenberg: No acne. Indigenous people, they don't even have a word for acne because they've never seen it. They don't know what it is. It just doesn't exist in those populations. So that's what I mean by saying, yes, hormones can absolutely be a trigger. But they're really not a root cause. It's really not a fundamental normal condition of humans to have acne because if it were, we would see it showing up in indigenous populations. And what we also see is there's nothing genetically blessed about these groups. When they move into westernized society or cities, they can and do develop acne. So it's really a function of Western lifestyle. And a lot of that, again, when we come back to the gut microbiome and we say, “Well, then how does that tie into these indigenous populations?” They have very different gut microbiomes than we do. A lot of it can come back to fiber. They eat 50 to 100 grams of fiber on average a day.

Jennifer: Oh, my gosh. That is so much. People … I'm like, “You need 35 grams,” and they're like, “Yeah, that's hard.”

Dr. Greenberg: That's what I do.

Jennifer: That's hard.

Dr. Greenberg: Yeah. The average American eats 12 to 15 grams of fiber. It's a small fraction. I also try to get my patients to 35 grams of fiber a day because when we say you are what you eat, it's because your microbiome is what you eat. And they are crafting a completely different microbiome than we are, certainly starting with the fiber, also though, the lack of packaged foods and chemicals, they're not exposed to antibiotics. They're not taking Advil and other medications. So we have a completely different gut microbiome than those indigenous populations. And again, for me, acne comes down to that gut microbiome.

Dr. Greenberg: And so with my patients, I'm not just treating candida, H Pylori, and protozoa. We are working on, okay, we're going to get up to 35 grams of fiber a day. And this is your new lifestyle because I don't want to just clear the acne. I want to clear it for good. And what I talk to patients about is if we don't change the way you eat and start really crafting that beneficial microbiome, until you start looking like those indigenous people in your gut, you're still at risk for that acne coming back, and nobody wants that.

Jennifer: No, no, no. And I wanted to ask you because you did mention antibiotics. And antibiotics tend to be the go to, one of the go to things. I mean, obviously, there's Accutane, which has a whole slew of other issues with it. But when I was a teenager, I was on tetracycline for two years maybe. It was a long time. So do you have to go the antibiotic route? Are there other options? Do you believe in the philosophy that the antibiotics could be used at a low dose for their antiinflammatory impact? I've heard that a number of times because they're discounting all of the things that you've said, which I'm so grateful that you've published a paper to show, yes, actually, there are some internal issues that you do need to pay attention to. But what's your take on the antibiotics option? Is that it?

Dr. Greenberg: Yeah, I'll first state for the record, I am not anti antibiotics. I actually prescribe antibiotics for certain things. I think they're useful in full blown infections when you need to quickly clean something up. Antibiotics absolutely can be lifesaving and there are appropriate times for people to take them. That being said, I do not subscribe to the low dose antibiotic regimens, either for acne or rosacea, because they're done in both. And it's exactly what you mentioned. They are not even high enough to be antibacterial. So we know now that at the dose that we're giving patients long-term like doxycycline or minocycline for acne or for rosacea, we're not killing bacteria, or not killing off the pathogenic bacteria. But we're certainly making changes to the gut microbiome. And the explanation that dermatologists give for dosing it is as you said. It's this air quote, antiinflammatory effect. And it was hard for them to quantify it.

Dr. Greenberg: But the thing that I was talking about, FOX01, that I know I kind of skipped over and it's hard to understand, the FOX01 is good. And what we have actually found in studies is that the tetracycline like doxycycline and minocycline increase FOX01, and so does isotretinoin or Accutane. So this whole mechanism of increasing FOX01 and letting it help control the sebocyte and sebum production is there, so that's part of at least the mechanism. But it's certainly not the path I'm going to go. The minute somebody stops the antibiotics, the acne tends to come back, so it's suppressive, and now you've kind of wrecked their gut by leaving them on it for months or years at a time.

Dr. Greenberg: Now they tend to do three or four month cycles and see what happens. But again, it really tends to come back. You haven't fixed anything. It's just suppressive, so that's certainly not the path that I go. And it's completely unnecessary. I use herbs and other things to go in and fix the gut. And I don't think antibiotics or Accutane is necessary for most cases of acne.

Jennifer: That is so helpful. And I'm sure there's people who are going to hear that and be like, “Oh, wait. I have other options. I don't necessarily have to do this.” And again, it's not to say, and I too, I'm not anti antibiotic. I have had to take antibiotics in the last year because I got bit by a tick. It happens. Like you said, there's a time and a place for medications. But if there are other options and we could kind of pull back a little bit, and like you said, not just fixate on triggers, but also say, “Is this really going to change this pattern, this habitual pattern that your skin or whatever seems to be in?”

Jennifer: Can we address that and make substantial shifts back in the direction of balance or health essentially? And that is so cool to know that there are dietary options, like you said. That's a really easy tip for anybody listening, especially my friends that are kind of veering toward carnivore because there's a lot of promises of carnivore. But I've seen a lot of problems with carnivore, unfortunately, more so in my practice. So I'm not alone in that. You've seen problems with carnivore.

Dr. Greenberg: Yeah. What I see with the carnivore diet is a profile of dysbiosis, what we call insufficiency dysbiosis. And when we look at the normal commensal bacteria, the healthy ones that we want in appropriate numbers, it's low, low, low, low because they eat fiber. And when you switch to really eating more meat, you're starving out the beneficial bacteria. They're waiting for you to feed them fiber, and if you're not feeding them, they're going to die, so that's a big problem. And mean is high in an animo acid called leucine, and out of all amino acids, leucine is the one we know that drives sebum production.

Jennifer: Interesting.

Dr. Greenberg: Yeah. Meat in appropriate amounts is absolutely good and healthy. And I don't have any issue with it. But when people are sitting down and eating a pound of steak, or shifting to a carnivore diet where there's so little plants and just a lot of meat, they can be driving acne. By far, the number one food that is correlated with driving acne is dairy, dairy of any kind, and there's really no doubt about it.

Jennifer: Does that increase? Does that decrease the … Does it have anything to do with that FOX01 you had mentioned?

Dr. Greenberg: It is related, so in two ways. Actually, dairy proteins, casein and why, so they're high in leucine, that amino acid we just talked about. But they drive that mTOR pathways. So the two pathways that we're talking about, FOX01 is your friend. And mTOR is not your friend in acne because mTOR is going to drive that sebum production and skin cell. Now mTOR again, it's a healthy, it's a growth pathway. So when we think about us as humans, there's two times when we have mTOR going bananas appropriately. Infants need to grow like crazy to survive. And then teens in puberty are growing like crazy. So mTOR is already naturally activated in puberty, and that's kind of why we see this perfect storm of mTOR, if it gets a little bit further than it should, and FOX01 can't control it, that's why teens are so at risk.

Dr. Greenberg: But the problem with dairy is when we drink dairy, we're supposed to be a baby mammal. And milk is filled with growth hormones. And so every time we take dairy, those growth hormones signal that mTOR pathway, hey, I'm a baby mammal. And mTOR, this is a life or death situation. You better make me grow like crazy, or I'm not going to make it. I have to become an adult and become a self sufficient mammal. Right? So every time we have dairy, it's driving that mTOR pathway as hard as it can. It's a really life or death issue for baby mammal to grow.

Jennifer: That's an interesting point that you make because I've had other guests mention about why dairy is not great for acne, but this is a whole different … That's a really interesting point.

Dr. Greenberg: Yeah, yeah. And we know, and of course we know we're the only species that drinks milk into adulthood. We're the only species that drinks another species' milk. And I always talk to my acne patients and I say, “Look, we're not having a debate about how delicious dairy is.” I mean, I love it. If you put a block of cave aged Gruyere in front of me, that block of cheese is in trouble. It's delicious, but it's not an appropriate food source for us as adult humans to be drinking milk, or milk of another species. And it really drives this mTOR process, and it will drive acne. Then the negotiation. What if it's yogurt? What if it's cheese? In any form, and from any mama mammal, it doesn't matter if it's camel milk, or donkey milk, or cow's milk.

Jennifer: You've heard it all. It sounds like you've literally been asked [crosstalk 00:33:53].

Dr. Greenberg: People will just start to negotiate. What about this? What about that? It like, “No. You've got to … “If you want to do a plant based milk, that's not real dairy and that's fine.

Jennifer: But protein powders would also be included in this because whey, a lot of those whey … So no whey, for those of you who can't, who are listening to this, we got a thumbs down from Dr. Greenberg on whey protein powder.

Dr. Greenberg: The worst thing you can do. And some of especially my male teenage patients come in on whey protein powder because they're trying to bulk up, and they're bulking up their sebum production is really what's happening. Yeah, we don't want that.

Jennifer: Well, this has just been incredibly enlightening. And again, congratulations. This is so cool that you're publishing on this and that it's been … You've had posters in different conferences. I'm so excited. And hopefully as, I know you're going to continue this kind of work also in other skin conditions, so hopefully we can talk more about that as these papers and posters are published, so that we can keep people up to date on your work, and the information too that maybe they could be like, “Hey, my own dermatologist, did you see this new research?”

Jennifer: We kind of have to be some of the messengers sometimes and be like, “Hey, did you see this?” And hopefully expand the horizons of what they're currently talking about in the conventional world so that we can get better results for everybody and overall better health. I think that's the goal at the end of the day. But thank you so much. And you again, you see patients. Tell everyone. You have this thing because you're a naturopath and so you have restrictions of what states. But if anyone is in California, Washington and Oregon, is that correct? You take patients from those states.

Dr. Greenberg: That's correct. Yes. So naturopathic doctors are licensed by state. We didn't get any kind of expansion with COVID, so I can only see patients who live in Oregon, Washington and California. I work via telemedicine. I've been exclusively telemedicine for the past year and a half due to COVID, although my offices are located in Los Angeles. If your patients are in other areas outside of California, Oregon and Washington, they can contact me. Or your listeners can contact me and I can try to help get them to somebody who may be able to help them, but I won't be able to treat them myself.

Jennifer: But you are available, and if somebody lives in that area and they're struggling, you are an amazing resource. Thank you so much for being a good friend and an expert, always coming back and sharing amazing information with everyone here. Dr. Greenberg, I deeply appreciate you and I look forward to one of our future conversations.

Dr. Greenberg: Thanks so much, Jen. As always, it's been a pleasure being here.

What I found was three things that kind of typify the acne gut. One is H Pylori (Helicobacter pylori)  is present. One is candida. Candida is elevated or high. And the third thing is protozoa.