304: Gut Microbiome Impact On Psoriasis w/ Dr. Fabrizio Galimberti

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Today we get to talk about the gut and skin connection that can commonly show up in psoriasis patients. Research is now demonstrating that the “psoriasis gut” looks eerily similar to those who have inflammatory bowel disease (IBD). AND IBD is one of the many co-morbidities of psoriasis, so this is important for every person with psoriasis to know especially if it's not something your doctor has discussed with you.

(ALSO — I've talked about the liver + metabolic comorbidities associated with psoriasis in a previous episode HERE.)

While not all doctors are up on the latest research, my guest today is AND completely agrees that there is a distinct connection between psoriasis + the gut microbiome that we all should be aware of!

Today's guest is Dr. Fabrizio Galimberti who is returning to the show.

Dr. Galimberti completed his medical training at Cleveland Clinic Lerner College of Medicine-Case Western Reserve University, received his doctorate degree from Dartmouth College and his residency at the Jackson Memorial Hospital-University of Miami Miller School of Medicine where he also served as chief resident. Dr. Galimberti's research interests include oncodermatology, autoimmune connective tissue diseases, and impact on quality of life of dermatologic conditions. He has published numerous articles in prestigious journals as well as presented his work at international conferences.

Have you heard of the “psoriasis gut” or done any research on the gut microbiome of those with psoriasis? Let me know in the comments below!

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

In this episode:

• Why psoriasis is NOT just a skin condition
• Is there a distinct common connection between those with psoriasis + those with IBD or Crohns?
• Interesting research on diet impact on psoriasis vs those without the disease
• How the gut microbiome varies from person to person (and some specific roles it plays in your health)
• Strep, tonsillectomies + other viral triggers for psoriasis (including COVID)

Quotes

“It is a systemic disease. You see psoriasis, but psoriasis does not start on the skin. It starts inside your body.” [01:15]

“We do know that strep particularly can cause (a flare), but there's quite a lot of data out there that also suggests, for example, HPV or human papilloma virus, may be related to that.” [21:47]

Links

Dr. Galiberti's medical practice

Healthy Skin Show ep. 069: Is Psoriasis A Gut Problem?

Healthy Skin Show ep 117: Can A Strep Infection Trigger Psoriasis?

Healthy Skin Show ep. 238: Inflammatory Connection Between Psoriasis + Depression w/ Fabrizio Galimberti, MD, PhD

304: Gut Microbiome Impact On Psoriasis w/ Dr. Fabrizio Galimberti FULL TRANSCRIPT

Jennifer Fugo (00:10.503)
Hi, Dr. Galimberti. Thank you so much for joining me back here on the Healthy Skin show. I really appreciate you returning so we can talk a little bit more about psoriasis and also the gut picture that tends to show up in psoriasis cases.

Fabrizio Galimberti (00:28.354)
Well, thank you so much. It's a pleasure to be back with you guys and I'm excited to talk about it. I think it's sometimes overlooked topic that I think will make a lot of sense for you and the other people online who are gonna listen to us. And maybe just by talking about this, everybody will come up with a different way to approach psoriasis, their own psoriasis and make them better.

Jennifer Fugo (00:49.619)
So let's start this off with talking about the fact that psoriasis is thought of in general as a skin condition, but I would argue, and I think perhaps you have the same mindset, that it is a lot more than that. Is that your thought as well?

Fabrizio Galimberti (01:06.862)
Absolutely, I completely agree with that. I think that even though we do see psoriasis, so we tend to think of it as a skin disease because it does manifest, of course, in the skin. It is a systemic disease. You see psoriasis, but psoriasis does not start on the skin. It starts inside your body. And that's also why I do believe that for many cases of psoriasis, not necessarily for all cases, but for many cases of psoriasis, we need internal treatment for psoriasis, not just on the skin. So sometimes the topicals might be sufficient, but sometimes we need to really attack something that starts from the inside through a medication that goes inside of us, whether it will be a tablet or an injection.

Jennifer Fugo (01:45.423)
And with psoriasis, it was interesting, I think about, I don't know, two or three years ago, I read research that stated that the gut of those who have psoriasis looks eerily similar to those who have inflammatory bowel disease or IBD. Do you agree with that statement, or what has your clinical experience demonstrated to you?

Fabrizio Galimberti (02:12.342)
I absolutely agree with this statement in a lot of ways. First of all, we do know that patients with psoriasis have an increased risk for inflammatory bowel disease, whether it's Crohns, whether it's ulcerative colitis. Now that's interesting because it links once again the skin to something internal. To me that kind of fortifies the idea that psoriasis is on the skin, but it doesn't start on the skin. It is a manifestation of an internal inflammation. Now, we all have skin, we all have a gut system. And of course there's a balance between all the parts of our body. Now what's very interesting is that there's bacteria that live on us. Sure. In modern times and the times of COVID, we always talk about how do we get rid of viruses? How do we get rid of bacteria? But they play a big role. Why? Because they allow us to actually live. Some of the bacteria in our body give us vitamin K. Vitamin K is something that we need to prevent us from bleeding out from a little cut. So we need to start thinking about the gut, the skin is connected of course, but also we need to start thinking about the overall players in here, of course us, our body, but also those bacteria that they're leaving on us rent free, but they're giving us things in exchange.

Jennifer Fugo (03:26.939)
They live rent-free but they're causing problems sometimes…

Fabrizio Galimberti (03:31.786)
Or sometimes preventing problems, right? Correct, so there's many studies out there as you pointed out that show that, well, even though we're all different and all of our bodies, my God, another person GI system, it's not necessarily the same, they do have similar trends in the type of bacteria that we host. And similar it's for our skin, we have different skin, but as long as we don't have a condition, a medical condition, our guts tend to share a common background of the type and even the number of bacteria in there. However, that changes when you have a medical condition, whether it could be inflammatory bowel disease or whether that's psoriasis. And what's interesting about what you mentioned is that patients who have psoriasis, only psoriasis, not IBD, but only psoriasis on the skin that we can see, their GI gut, the bacteria that lives inside their gut, is different than maybe their… wife who has the same diet if they live in the same location, but they have completely different bacteria. And the bacteria of presence in the GI, in the gut of a patient with psoriasis, start to become more similar to that of a patient with IBD, rather than a patient who doesn't have neither psoriasis nor IBD. So there is a big connection there.

Jennifer Fugo (04:48.819)
Can I ask too, sort of an aside, but connected, is that the same with psoriatic arthritis, that the gut would be similar in that regard?

Fabrizio Galimberti (05:00.158)
So you like to ask difficult questions. Those are really good questions, right? Difficult questions are what make us think. And the answer is a simplistic answer. The answer is most likely yes. What I mean by that is that whereas psoriasis we can see very well, psoriatic arthritis is a little bit more challenging. There is even a subtype of psoriatic arthritis that presents without skin involvement. Now those patients have psoriasis in their joints but not on their skin or not quite yet.

Jennifer Fugo (05:12.403)
Hmm.

Fabrizio Galimberti (05:29.93)
And in those cases, it's very difficult to diagnose, right? These patients might not go to a rheumatologist. They definitely might not go to a dermatologist because they have joint pain. And we're really missing some of these populations, but the more and more we understand these conditions, the more we see that, of course, psoriasis and psoriatic arthritis are quite similar, even though they might not be exactly the same. And those two together, they're very similar to inflammatory bowel disease when it comes to some level of inflammation. So the simplistic yes is most likely yes, but this is early in the study, in the microbiome study. We're kind of early here, but the data is starting to suggest a strong connection.

Jennifer Fugo (06:09.249)
So if we have, say, a clinician listening to this podcast, which they do, by the way, we definitely have doctors and other derms that listen to the show, if they were not aware that there is likely some link between psoriasis, at the least psoriasis, and internal gut issue, and they've been like, no, that's not a thing, would this be the invitation to say, hey, you need to start actually looking at the research that's coming out now?

Fabrizio Galimberti (06:38.638)
Absolutely, I think it's a strong invitation to do that. I think what's fascinating is that there's even more evidence out there. For example, as a dermatologist, I don't necessarily take care of patients with inflammatory bowel disease. They will go to a gastroenterologist, let's say. But the surprising thing, remember I told you that the two are similar in certain ways, is that the gastroenterologist might prescribe exactly the same medication that I would prescribe for a patient with psoriasis.

So that underscores that there is a strong connection. Remember, in the era of modern medicine, we now treat psoriasis by targeting specific molecules. And these same specific molecules that are deregulated in psoriasis are also deregulated in inflammatory bowel disease. Furthermore, underscoring not only a connection in terms of a disease state, but truly a molecular connection and inflammatory connection between the two.

Jennifer Fugo (07:32.191)
That's a really great point to bring up because I have had, for those of you listening, if you're not familiar with some of this, you might wanna go check out Dr. Heather's Zwickey's interview on biologic drugs, where she did actually really dive into this deeply. So if you wanna nerd out on it a little bit more, we definitely have that available for you. So if… you're considering now like this is a much bigger picture than just a skin problem. What are some of the alterations that you tend to see either in the research or that you've seen in your clinic that look different about the psoriasis gut as compared to, like you said, the wife of the patient who might eat the same exact thing, doesn't have psoriasis, what tends to be the difference that you have observed?

Fabrizio Galimberti (08:27.79)
Now, and I think it's important to underscore the fact, of course, that we're comparing against somebody who doesn't have psoriasis but shares pretty much everything else, right? Because diet, where you live, that can have a, where you drink, that can in terms of the water and so forth, that can have, of course, a strong influence in the type of bacteria that goes into your gut. Now, when they did a few studies on this, and of course, these studies are very difficult to do because it's difficult to get samples of what's inside your body. Additionally, there are so many different types of bacteria that this is kind of what we call big data, right? We get back so much data from these studies and then it becomes very difficult to compare between a group of patients and other ones. But what they have noticed is that patients who have psoriasis compared to patients who do not have psoriasis tend to have a different level of variability of bacteria into their guts. Now, let's, you know, we use the term bacteria broadly, right and it's probably not fair to call some bacteria good bacteria and some bacteria the bad bacteria, right? But in a sense there are such things. Now what's interesting however, and I want to emphasize that, is that sometimes what's a good bacteria in your gut? It's a bad bacteria on your skin. So the same exact bacteria. So the body is very complicated, right? Some bacteria are friends in the in the gut. Now these bacteria not only help us in degrading or absorbing some nutrients, but at the same time they help preventing the bad bacteria from growing rapidly. Almost like a competition. And once again, what they see in these preliminary studies is that the gut of the person with psoriasis tends to lose a little bit of the viability, the strength, the number of what they're considered good or healthy bacteria in the gut. That allows the other not so good bacteria to overgrow the area, to overgrow and really take over; and when they take over something interesting happens. Of course the bacteria is there and yes some metabolic byproducts that they secrete into the gut and this causes inflammation and when you have inflammation in the gut, the skin in the gut, think about the guts will have some sort of skin, that actually gets leakier. So you have a chance of absorbing more toxins and so forth and then what happens? You get more systemic inflammation and psoriasis is nothing else other than inflammatory condition. So any chances, anything that causes your inflammation to get higher inside the body will cause your psoriasis to get worse or perhaps even present for the very first time. Remember, we don't know why patients get psoriasis yet at this point. We don't know what's the initial trigger. Perhaps it is that change in bacterial flora that triggers the systemic inflammation.

Jennifer Fugo (11:17.019)
Is it also, and this is just me asking the question because I know that people do talk about genetic predispositions. Is it possible that maybe because of, we talk about epigenetics too, maybe there's exposures and the way the gut bacteria change and waste, I mean, it's obviously complicated, but maybe that too, it plays a role in the genes that somebody has.

Fabrizio Galimberti (11:44.294)
I think you hit a very good point. There's definitely this genetic predisposition and there's definitely some sort of trigger, maybe more than one trigger that happens and causes this. However, the genetic predisposition is something that we cannot change. We don't choose our mother, we don't choose our father. We inherit their genes. But what we can change is how we use those genes, right? How in our diet, for example, in how we… how many toxins we expose ourselves to, pollution and so forth. So those are the modifiable factors that play a big role in aging and disease states as well. We will all age, but this exposure, this how we interact with the world will change the way that we age, for example. Similarly, we'll change the rate of disease that we will unfortunately suffer.

Jennifer Fugo (12:32.923)
So with someone… if they have psoriasis and they now you know you potentially have a microbiome that perhaps is shifted in a direction that might not be in your best interest. And I want to be very clear here just because I also work with clients in this state. You're not stuck. I think that's a really important point. The genetic thing, like you said, you can't trade in your genes for, you know, you can't trade in for different cards You're stuck with what you got. But with the gut microbiome, it's malleable. We have the ability to change things. So what do you think are, at least from your experience, have been helpful tools or steps that potentially could be taken by those who have psoriasis in regards to this whole gut microbiome piece?

Fabrizio Galimberti (13:27.97)
First of all, we do know that no matter what, a healthy, balanced diet helps not just psoriasis but cardiovascular disease, which is also something that patients with psoriasis have an increased risk of. So nonetheless, a healthy diet should always be a good start. However, over the last few years, the concept of can we change the gut in terms of the bacteria that lives in your gut, can we change it by what we eat, has become really prevalent in the literature. So the use of probiotics and prebiotics has really boomed, and the idea of using those as medications has really made an entryway into the pharmaceutical world. Can we use bacteria almost as a medication? Now, this is not necessarily something too new. Now, as a physician practicing the Western medicine, I go back all the way to ancient Greek, and Hippocrates was probably the very first Western physician that we can think of.  And he actually said that there is a strong connection, and he used a sentence, he said, let food be thy medicine, and medicine by thy food. So there is something that we knew for a while. And for example, let's think of one of the most common skin conditions, acne. We all know that some foods trigger acne. And guess what happened over the last few years? We have learned that the gut microbiome and the skin microbiome is incredibly important for that. Let's think of another condition, atopic dermatitis or eczema. Atopic dermatitis is incredibly common, particularly in young kids or in adults, but mostly in young kids. And it's been known for probably centuries at this point that maybe yogurt, a little bit of yogurt, something that is rich in probiotics, something like kefir, actually can help quite dramatically in cases. It might not be sufficient for cases of moderate to severe atopic dermatitis, but for the mild cases, it can really make a big difference.

So it's not really surprising that maybe we can use the same concept in psoriasis. And studies are finally coming out. We are starting to see the effect of some probiotics in psoriasis. Now, I don't know if you've ever taken a look at the name of bacteria. Bacteria is very complicated first and last names. I'm from Italy, so Latin is somewhat familiar to me. Even for me, those are complicated names, but I'm going to give you two names to think about. One is called Lactobacillus and the other one is called Bifidobacterium. Now these are somewhat well known because sometimes you do hear them in commercial perhaps. Why? Because even commercially available yogurts and other products are enriched with this. Now it might sound weird to enrich yogurt or something with bacteria, but these are the stereotype, the classic good healthy bacteria for your guts. So what happens if we feed patients with psoriasis, a diet that is rich in this. Well, the studies are coming out that not only they get less itchy on the skin, and psoriasis can be itchy, but with time, their plaques get smaller and thinner. Might not be enough for everybody, but it's a healthy add-on. It really has potentially no side effects. And a healthy diet will help your heart, will help your overall circulation, your risk of diabetes. So it's really something that will benefit your entire life, not just your psoriasis.

Jennifer Fugo (16:54.195)
Yeah. And what about fiber? Do you have any thoughts on that, especially now? You know, people go on to Instagram and on social media, and they're doing a deep dive on Google. And they are finding certain diets that tend to used therapeutically, like there's the carnivore diet that is all animal products and really completely devoid for the most part of fiber. And then you have the ketogenic diet, which really was more meant for people with seizure disorders originally, but is now being used by people. And unfortunately with the keto diet, it's 70 to 80% fat, which doesn't leave a lot of room for fiber. So for those who might have seen information online and that said that this was the way to go and now their fiber is limited, do you think that that, or at least from the research that you've seen, could be problematic for someone with psoriasis?

Fabrizio Galimberti (17:52.842)
I do believe that could be problematic. I do say could, why? Because there's not much strong evidence to say that for sure you should take a lot of fibers. However, we do know that fibers overall promotes the healthy bacteria in your gut. So a healthy gut means a healthy skin, which means overall healthy patients. So I would advise against anything that say that this is the right diet, but I would say that there are certain data suggesting that there is probably a better diet than another one. Of course, balanced diet, that would include fibers. Remember, fibers is not only good for your overall gut health, but it also will provide some micronutrients that you might need for overall health. So cobalt, for example, other minerals that are enzymes need to carry out their function. So usually a balanced diet does include fibers, so I will absolutely support that.

Jennifer Fugo (18:48.435)
I want to ask you about strep. Since strep can sometimes be a trigger for gut-hate psoriasis, what has your experience been? I've read some things that there's a high incidence sometimes of strep throat. What are your thoughts on strep in terms of being a possible issue for psoriasis?

Fabrizio Galimberti (19:12.21)
I think the evidence is strong when it comes to that, particularly in this subtype of psoriasis called Guttate psoriasis. And we do have some clinical examples that really solidify that. For example, in many cases in the late 1990s and early 2000s, tonsillectomies were done in patients who kept on getting strep throat and their psoriasis would flare. And the tonsillectomy resolved not only the strep throat but also their psoriasis. Now we don't do that quite that much anymore. We're very good at diagnosing strep throat. We're very good in treating strep. But that shows you that the skin microbiome, as well as your internal microbiome, and that already kind of counts for the internal microbiome and eventually the microbiome that will be in your belly, really can trigger a systemic inflammatory response that can lead to psoriasis. And perhaps the data sooner or later might show that can lead to other inflammatory conditions, one, rheumatoid arthritis. There might even be a connection to multiple sclerosis. And all those inflammatory conditions that we know happen, but we don't know why they happen. We say there might be some sort of exposure, a genetic predisposition, but we really cannot narrow it down to a single event. Well, that type of inflammation that triggers your immune system and triggers inflammation may be one of the most important events, and perhaps is a modifiable event.

Jennifer Fugo (20:33.415)
Do you, in your practice, do you ever look for strep? I know I had one client, she has psoriasis, and I think she also has psoriatic arthritis. I'm not 100% sure, but just off the top of my head. Her doctor did do that anti-streptomycin antibody titer. I think that's the name of it.

Fabrizio Galimberti (20:55.918)
Yes, yes. Yes.

Jennifer Fugo (20:58.627)
Do you ever utilize that marker at all? Do you think it's worthwhile?

Fabrizio Galimberti (21:04.078)
So I had in a few patients, and in few patients where I suspected that an infection was the possible trigger of psoriasis, I have done that before. Now of course, I think that's something that can help in the short term. Now that patient who had a flare of psoriasis because of an infection, of course, is going to be prone to other infection, just like anybody is. Maybe it could be COVID, maybe it could be any other virus, maybe the flu season, which is projected to be making a big comeback over the next year, over the next few years. So these patients are a little bit higher risk of having anything triggering the inflammation, their immune system, and leading to a bout of psoriasis. Now we do know that strep particularly can cause that, but there's quite a few data out there that also suggest that, for example, HPV, or human papilloma virus, may be related to that. So… We really need to, you know, it's early on in this field, but we really need to think about the fact that inflammation can be caused of course by an infection. Sure, now we know about strep, probably because strep is very common. There might be also some mimicry in the immune system, how it gets activated in a certain way by strep compared to other bacteria, other viruses. But we really need to stay away from inflammation. And that kind of goes back for a second to the previous questions about diet.

Now, a lot of foods are pro-inflammatory. So in general, what I suggest to my patients with psoriasis is number one, a healthy diet. But please take a quick look at different anti-inflammatory diets and see if there's a food that you really, really love and perhaps is really, really not recommended in those. And maybe let's try to reduce the intake. I never think that you should cut out something that you love from your life, but maybe we can try to reduce it, right? Now smoking is probably the only thing that I would say that even if you love it, you should cut it out.

Fabrizio Galimberti (22:58.09)
And there is a strong correlation between smoking and psoriasis and inflammatory bowel disease of course. And that may be once again because of the inflammatory nature, the inflammation, the response to smoking. But everything else I think in moderation should be considered. But let's try to avoid things that are pro-inflammatory. And that's been done for centuries. It's really something that is coming back into medicine now. We're very preoccupied probably over the last 100, 150 years in making new discoveries when it came to medicine. The new most complicated medication out there was always assumed to be the best and strongest medication. But now the medicine has gotten so far where we can target a specific molecule in psoriasis, a specific molecule in inflammatory bowel disease. Now we start to appreciate back the fact that there are other modifiable factors that when used conjunction to these phenomenal medications can make a huge difference.

Jennifer Fugo (23:56.131)
That makes a lot of sense. And actually, it's interesting, you brought up COVID. And I figure I'll ask you because I've gotten a lot of questions. So many people have noticed their skin, especially with psoriasis, but it happens with eczema as well, that they develop a huge flare-up, either after getting maybe a booster or after actually getting sick with COVID. Do you see that clinically or is it just me hearing a lot of people say and ask me about it, and any thoughts on why that is?

Fabrizio Galimberti (24:33.702)
I've seen that, I've seen quite a little bit. And I did think a lot about this because of course, COVID is something that we only partially understand at this point, but one thing that we can all agree about COVID, it's how inflammatory it is for the entire body. Indeed, if we go back to the very first wave of COVID, one of the first medications that were used were anti-inflammatory. Now there were anti-interleukins, but in general, there was something to slow down the immune system. The virus is powerful, but sometimes your reaction to the virus is just as powerful. And that's what brings around atopic dermatitis, something that is an inflammatory conditions, psoriasis, and other inflammatory condition, belly issues like IBD, other inflammatory conditions. Now, you bring up a good point, of course, the vaccines as well can cause inflammation because they do activate your immune system. Now, I think we can all agree that whereas COVID only brings bad stuff to your body, vaccines also gives you protection.

So there are a few patients who have developed flares of their conditions after their vaccines, but it's important to know that overall these patients were protected from a virus that can be deadly. So always the balance between the positive and negatives. But once again, there is only one thing in common in all of those conditions, inflammation, right?

Jennifer Fugo (25:52.563)
So it's possible then that the inflammation that COVID creates could exacerbate the current situation. What someone had said to me was it's like almost like COVID finds where your like weakest link is and it makes it worse and amplifies it, which was my experience with my back, which felt completely crazy, but that was my real life experience that could not be explained by any like… physiology, something have having happened to me, there was no accident, it was just literally the inflammation from the infection. So, so for anyone who's out there, who's like, I feel like I got COVID and my symptoms got really a lot worse. They're not crazy then to feel that way.

Fabrizio Galimberti (26:46.75)
Absolutely not. I'm going to say your story is shared by so many other people, including myself. Now after COVID, many people might not have these changes, but many people will. Just because you don't know anybody next to you that does, does not mean that you're the only one, does not mean that you're dreaming about this or that you are crazy. You're just noticing something that might have happened with the inside your body. Now the thing that I thought was also interesting thinking about this conversation is that sometimes having COVID can actually be one of the environmental triggers that we talked about. We don't know why psoriasis happened. So it's been actually quite common. And I've seen quite a few patients that never had psoriasis. Maybe they had a family history of psoriasis. And after COVID, now they start to present with psoriasis. Even though they really thought that they were never going to have it, just their dad or maybe their grandpa had it, after COVID, the psoriasis shows up for the first time. The good news, at least in these cases, where it's the first presentation of psoriasis, that as time passes from the exposure to COVID and the immune system goes back into the pre-COVID state or just on a memory of a COVID state, their inflammatory conditions tend to improve. But that really tells you, we don't know what the cause of psoriasis is. It could be many. It could be a virus as well, right?

Jennifer Fugo (28:08.127)
Hmm, that is very helpful. I think that's really helpful because I've been asked this so much and I just am like, well, I know other people are asking me this so you're not alone, but I think it's helpful for people to hear from a dermatologist like yourself that they're not crazy, that this could possibly cause a flare up of their skin.

Fabrizio Galimberti (28:26.286)
Not only that, I think the other thing that we're seeing a lot with an interesting virus like COVID, it goes back in the systemic inflammation is that we're seeing a lot of patients that develop a type of hair loss that is secondary to inflammation. That's called telogen effluvium. It's very common for patients after having COVID to start seeing shedding. And sometimes patients wonder, am I just being more attentive to that? Or am I really dreaming about this? And it's basically impossible to count how many hair you shed every day. So don't collect your hair and count them. If you feel that you're shedding more hair after COVID, you probably are. Now the good news, and I wanna reassure you, is that the vast majority of cases will be self-resolving and the hair will eventually grow out. So if you're at home and you're listening to this and you're thinking, well, I did get COVID, but I didn't get psoriasis. But I feel like I lost more hair. That's actually a very, very common.

Jennifer Fugo (29:29.519)
Well, thank you so much for sharing all of that because I think it's a helpful reminder for listeners to hear the different opinions and experiences and what you see clinically because they may only have exposure to their dermatologist that they see every few months or maybe once a year and sometimes you just don't know if what you're experiencing is normal. And also this is an invitation for listeners and even other practitioners listening to the podcast, if you haven't been making this connection of digging deeper than psoriasis just being a skin issue, now you know there's a potential gut component that there is research on that we are seeing more and more research about. And it's also a malleable area, we can actually help support that beautiful ecosystem within the GI tract and support our body better.

Fabrizio Galimberti (30:27.53)
And you know, I think you use a very important word, the idea of a beautiful system. Now, one of the things that motivates some of my patients is health, and one of the things that motivates some of my patients is beauty. Now, talking about the microbiome actually has a little bit of a connection to health, as we saw before with the inflammation, but also with beauty. So the idea of actually nutricosmetic- nutrients that are cosmetics- is actually coming into the field and guess what are the number one things that are being studied right now. It's actually pro and prebiotic. So let's say that you could do something that number one is gonna help your overall lifestyle. Number two may make you prettier or prevent aging. Number three can help your psoriasis, let's say your IBD and just as importantly as virtually no side effects. That's pretty good. So it doesn't matter if you do it for beauty or for health. I think that in the near future we're going to start looking at pre and probiotics almost as medications or natural supplements to medications rather than something that we just go and get from the refrigerator.

Jennifer Fugo (31:40.103)
Yeah. Well, thank you so much for sharing all of your thoughts today and coming on and talking about the research that supports this concept that psoriasis is just so much bigger. I mean, even the last time we spoke, we talked a lot about stress and that the anxiety factor and how psoriasis can be connected to depression. So we'll definitely make sure to link up to your other episode in the show notes. And you are practicing in South Carolina now?

Fabrizio Galimberti (32:08.61)
That is correct. We recently moved to South Carolina. We're in the Myrtle Beach area. We're excited to be here. It's been an interesting change. Now, of course, skinny skin. So no matter what state of the union you're in, a healthy diet and a healthy skin go hand in hand.

Jennifer Fugo (32:28.659)
That is true. And we'll make sure to put your new listing for where you're practicing into our show notes. That way, if anyone's listening, they can find you and connect with you in person, especially if they're looking for a dermatologist to help support them. Yes, thank you so much for being here, Dr. Galimberti. I really appreciate it.

Fabrizio Galimberti (32:46.35)
It's been a pleasure. Thank you so much. See you soon, take care.