102: How Internal Inflammation Impacts Chronic Skin Rashes w/ Dr. Will Cole

How we're doing internally is an important piece of the skin rash puzzle, even though they manifest externally. My guest today is going to talk all about inflammation, and its impact on chronic skin conditions.

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My guest today is Dr. Will Cole, leading functional-medicine expert. Dr. Cole consults people around the world via webcam at www.drwillcole.com and locally in Pittsburgh, Pennsylvania.

He specializes in clinically investigating underlying factors of chronic disease and customizing health programs for thyroid issues, autoimmune conditions, hormonal dysfunctions, digestive disorders, and brain problems.

Dr. Cole was named one of the top fifty functional-medicine and integrative doctors in the nation and is a health expert for mindbodygreen and goop.

He is the author of The Inflammation Spectrum, in which he explores how inflammation exists on a spectrum within the body, the various systems it can affect, and how you can discover your individual food triggers to overcome chronic inflammation. He is also the author of Ketotarian, in which he melds the powerful benefits of a ketogenic diet with a plant-based one.

Join us as we discuss how inflammation is a key component in many chronic skin conditions.

Has working on inflammation helped your skin rash? Let me know in the comments!

In this episode:

  • What is inflammation?
  • Low-grade chronic infections
  • What are Th1 and Th2?
  • Why high-sensitivity C-reactive protein labs might be more valuable in terms of looking for inflammation
  • A few helpful lifestyle changes


“Inflammation is not inherently bad. We need it to fight viruses and bacteria and heal wounds and keep our bodies nice and healthy. The problem is when inflammation is out of balance…” [2:19]

“Skin problems do not happen in a vacuum. They are happening for a reason, and oftentimes it's an internal.” [10:41]


Find Dr. Cole online

The Inflammation Spectrum book

Ketotarian book

Elixir guide for inflammation-healing elixirs FREE DOWNLOAD

Find Dr. Cole on Instagram | Twitter | Facebook

102: How Internal Inflammation Impacts Chronic Skin Rashes w/ Dr. Will Cole FULL TRANSCRIPT

Jennifer: Hi, everyone. Welcome back. Today I am joined by Dr. Will Cole. I'm so excited to have him here with us. And so we have talked at length about how inflammation is a huge component to so many of these chronic skin conditions. And even with like eczema, for example, what do we always hear? We have to find where the inflammation is coming from because that can dysregulate all sorts of things in the body that then drive flares and whatnot. And we see that even in the more autoimmune type of conditions like psoriasis, as well. And so I thought that I would have Dr. Cole here with us today to talk a little bit more about inflammation that's generated internally because a lot of times with skin issues we just think about what's going on the outside, whether it's a fabric rubbing against our skin or an allergen or even sometimes just food allergies or pet dander, things like that. But there's plenty of things that can cause inflammation internally that we don't quite know exactly what's going on. And that's where it can become murky and figuring out what some of these root cause triggers are for your rashes. So Dr. Cole, first of all, thank you so much for being here. I really, really appreciate it.

Dr. Cole: I mean, the pleasure's all mine. I'm excited to talk to you about this important topic.

Jennifer: Yeah. And so why don't we actually start off by talking about what exactly is inflammation. Again, most people fixate on the idea of it being an external factor that drives inflammation, but what about the stuff that happens internally? It's not like we're damaging organs. It's not like you were in a car accident or you fell downstairs or had some sort of trauma. This is a different type of inflammation that we're talking about.

Dr. Cole: Yeah, it's chronic inflammation or chronic insidious inflammation where it's not the overt acute implement inflammatory response of, like you said, like some injury where if someone's, God forbid, in an accident or a sporting injury, things like that. This is chronic inflammation is like this low-grade forest fire that's burning in perpetuity. That's really the commonality between just about every health problem out there is chronic inflammation. Inflammation is not inherently bad. We need it to fight viruses and bacteria and heal wounds and keep our bodies nice and healthy. The problem is when inflammation is out of balance, just like so much of our body, like our gut microbiome, we want balance, our hormones, we want balance, and with inflammation we want balance. It's the Goldilocks principle. It's not too high, not too low, but just right and just right when we need it, too.

Dr. Cole: So I think that's really the problem. And when we see things on the skin from a functional medicine standpoint, and when I consult patients online, this is typically how I'm trying to get them to understand what's going on in the skin has its roots somewhere else. And oftentimes, in functional medicine, we see almost the skin as a reflection of what's going on in the gut and almost seeing the skin as a reflection of the gut lining. And there's a lot of similarities between that. So if you see inflammation and flares and irritability on the skin, there's going to be almost always, or certainly in a vast majority of people, irritability and flares going on in the gut lining as well. It's a gateway between what's in the gastrointestinal system and what's outside of it in the bloodstream.

Dr. Cole: So about 75% of our immune system is in our gut, in our gastrointestinal system. One of the things we look at in multiple ways we run labs to find out these underlying root triggers to skin problems. So to understand what's going on in the skin, oftentimes, you have to look at what's going on in the gut as your audience. Many of your audience members probably already know because there is, what is referred to in the scientific literature as, the gut skin access or the connection between the gastrointestinal system and the skin, and that's just one component of inflammation. But gut-centric inflammation or inflammation originating in the gut as specifically to skin issues is very common. Now we don't want to be overly myopic and single minded and saying what's only the gut. Gut is just one component to it, but we have to look at chronic infections broadly beyond the gut to systemic chronic infections, like Lyme disease and coinfections, and viral infections, like Epstein-Barr virus and cytomegalovirus and human herpes 6 virus. These other chronic infections and co-infections can trigger this inflammatory response to that. I have also seen be a component to some people's skin flare and there's somewhere on this sort of autoimmune inflammation spectrum that I talk a lot about. So that's what we look at in functional medicine to understand the roots of skin issues.

Jennifer: Now let me ask you a question that I actually have gotten a lot lately, and most people are surprised. They'll say, “Well, I'm not really sick, but you're saying I could have some sort of infection?”

Dr. Cole: Mm. Yeah. So it's, again, a low-grade chronic infection. People think of it as like a cold and flu and having reoccurring like sinus infections or things like that; that's not what we're talking about. It's a low-grade chronic infection, just like low-grade chronic inflammation. People don't necessarily have to have the run down and have like a cold and flu all the time, even though that can happen. It all depends on how the immune system's modulated and any other opportunistic viruses and bacteria that can take advantage and some people do have chronic infections like that. But many people, if anything, their immune system is over-reactive, they're in a state of chronic inflammation, where they don't necessarily get run down with lots of colds and flus and things like that their immune system's in overdrive, but it's a lack of balance and that can be seen with many people too. So it all depends on how the immune system is modulating. People with autoimmunity and people with autoimmune components to their cases may not have full-blown autoimmune conditions, but they have Th1 and Th2. These are the two sort of aspects of the immune system and you can have an imbalance of that, and that can definitely drive immune dysregulation in the body.

Jennifer: And can you actually break that down a little bit further for my audience because we've never really talked about Th1 or Th2 before, and they might not really even know what that means in the grand scheme of things. You have like a simple analogy to make two so they could understand.

Dr. Cole: Sure. Yeah. So there are basically two different components and how the immune system behaves and operates in the body. So we all have Th1 or Th2 immune system and then you have this third component or T regulatory cells that help to balance out that immune system. So immune system, like I talked about the Goldilocks principle with inflammation, this is part of that Goldilocks principle. You want to have balance Th1 or Th2 or a balanced immune system. And that is lost with a lot of people with pro-inflammatory problems. Again, whether it's a full-on autoimmune condition like psoriasis or psoriatic arthritis or Hashimoto's disease, any other autoimmune condition or autoimmune adjacent issues or inflammatory problems or there may just be a component to it that looks autoimmune in nature and there is a lack of that balance. So you can have what they call Th1 dominant or Th2 dominant. So that's when the immune system is a Seesaw, that's a lack of balance, and we want balance in their body. We want balance of Th1 or Th2. and part of that is supporting Tregs, or T regulatory cells, which helps you regulate that seesaw to keep it balanced. So a lot of the things that we look at when we're understanding these inflammatory health issues, skin issues or autoimmune flared skin issues is supporting the T regulatory cells and/or down-regulating and calming the dominant side of the immune system.

Jennifer: Okay, that is very helpful. And I'm sure that people who aren't familiar with those terms are going to be really appreciative that you shared that. With us said, with skin folks… Skin folks, I used to have eczema. I knew there was inflammation but it always appeared on my skin. Is it possible to, even though you have a skin issue, that you could have, and we talked about gut briefly and we know that gut… You certainly can have inflammation there. But is it also possible to have inflammation show up elsewhere in the body that someone might not even realize because they're so hyper focused on their skin?

Dr. Cole: Yeah, absolutely. You don't necessarily have to have overt digestive symptoms that have underlying gut problems. You don't have to have overt other systems in the body to have measurable inflammatory processes in the body. I mean that's just very, very common where you can measure on labs. And we run labs for these young patients, but things like high-sensitivity C-reactive protein, measuring homocysteine and engaging methylation, looking at a ferritin as an acute phase reactant, which is another way to gauge inflammation. Looking at gut-centric inflammatory proteins, like calprotectin and lysozyme, lactoferrin. For many people, they're not noticing, “Okay, my gut's inflamed.” Even though they could, but many people don't. They think, “Oh, man, maybe I have a little bit of bloating here and there. Maybe I have some digestive problems,” and maybe they don't notice any of it. Whether that is because they're just not in tune with their body or because they really aren't having any significant issues, but yet you can quantify these on labs, so I see all the time is that you go upstream to these other components of the body. You look at the inflammatory markers, and you can look at what's driving that inflammation, like a chronic infection or I've got problem more of nutrient deficiency, whatever the case may be. And then you see it and you're measuring these things, but the person wouldn't know it until they ran a lab. So yeah, it's very, very common. I mean, skin problems do not happen in a vacuum. They are happening for a reason, and oftentimes it's an internal. Now, of course, external care and dealing with the external factors like you mentioned are certainly a component to that, too, but it's a piece of the puzzle. I mean, you just deal with the external, you're not dealing with the other side of the puzzle.

Jennifer: Yeah. I wanted to ask you about one of the specific markers that you mentioned, the high-sensitivity C-reactive protein. It's almost like there's two of them. There's C-reactive protein and then little hs C-reactive protein. People ask me all the time, they're like, “Well, what are some good labs they should ask for?” And that can be helpful. Could you explain like what the difference is between the two, and why high-sensitivity C-reactive protein might be more valuable in terms of looking for inflammation?

Dr. Cole: Yeah, and both can be fine. There's C-reactive protein, which is the standard one and a high-sensitivity C-reactive protein, which is a little bit more sensitive, and I think you can pick things up a little bit more for inflammatory health problems. Typically both of those labs are ran, and whether it's hs-CRP or CRP, it's ran traditionally for cardiovascular risk factors. So the American Heart Association, the CDC have these guidelines that you will see on lab markers to look at. Low, average and high relative risk for inflammatory problems and cardiovascular risk factors. But there's a lot of health problems, really almost every inflammatory health problem you can think of could, in theory… You could see a spike CRP going on there. So it's nonspecific. It's not saying exactly where that inflammation's at. It's not saying exactly what's driving it either, but it is saying, “This is a general idea. This is the general quantification of inflammation in the body.” That it's not good, that it's associated with a lot of different health issues, and you don't want inflammation levels being high. So you both need to understand, “Hey, we need to lower that inflammation,” but also we have to ask what's driving that inflammation and go upstream.

Dr. Cole: It's like a check engine light, but it's also something to deal with as well. hs-CRP is a surrogate lab for something called interleukin six or IL-6, which is also another pro-inflammatory cytokine that is associated with all of these other different types of autoimmune and chronic inflammatory health problems. So it's a good lab, and as you mentioned, it's very accessible. Most people can get this from their standard doctor. They don't necessarily have to have a functional medicine doctor run that. And same with homocysteine, too. It's another pretty low-cost test, accessible test for people to gauge. So for hs-CRP in functional medicine, you want that C-reactive protein to be under one. And homocysteine with just the other inflammatory marker. In functional medicine, we went homocysteine to be under seven. So those are two basic tests that people can run.

Jennifer: And what about ferritin? Do you ever use ferritin as a marker for inflammation?

Dr. Cole: I do. Ferritin is another inflammation spectrum lab that I run, which is a biomarker to gauge for stored irons. You normally want to put ferritin in context with iron and iron saturation and total iron binding capacity. Put it in context, but sometimes you will see ferritin, and I see it probably on an hourly basis because I consult patients with inflammatory health issues. So I don't necessarily see your average group of people, but I normally will see even lower iron to normal iron, but have really high spike ferritin levels. How could that be? If you hung your hat on just the basics of it, you would standard diagnostician or even a lay person and would probably say that's iron overload. Well, not necessarily. Ferritin is considered an acute phase reactant. So basically in states of inflammation, you can see ferritin spike or they typically go basically anemia of chronic inflammation. It's basically this chronic inflammatory response that's going on that's causing that high ferritin to be there. So you'll see ferritin above 250, basically, you'll see above those that number and then you want to make sure it's not iron overload or hemochromatosis. You definitely want to look at that and vet that, but it definitely can be one way to gauge inflammation, too.

Jennifer: Yeah, and so you wrote a book, which is really fantastic, that came out a few months ago called The Inflammation Spectrum. That was really what prompted me to talk to you. I was like, “I have to get this guy to come on the show because this is such a perfect topic, and especially we're kicking off the new year with this. It is perfect.” You know a lot about inflammation. How did you wrap all of this into something that you could really share with people so that it was understandable because this is complicated?

Dr. Cole: Yeah, it is quite nebulous for many people. It's very dense. Honestly, it took me quite awhile to break the book down to the point where it made sense to a reader because when I'm not there to like lead somebody. Like when I'm there for health history and a consultation or clinically monitoring a patient, I can make it make sense because I'm with the person, proverbially speaking, online. But it's harder when you want the reader to go through this adventure of exploring what works for their body and what doesn't and healing themselves and using food to heal themselves and using non-food things to heal themselves. It took awhile, but it's a concept that I see on an hourly basis. This concept of the inflammation spectrum from mild symptoms, maybe like some mild skin issues to low-grade fatigue, background anxiety, maybe some mild bloating. And then all the way to the other end of the inflammation spectrum, which is either an autoimmune condition or hormonal imbalance or a metabolic issue, or any other sort of ICD-10 diagnosis code that somebody could be diagnosed with, and then everything in between.

Dr. Cole: It's really the heart of what I do. The hard part was making sense to reader. We worked really hard on it, me and the publishers, to have it make sense. And we just kind of start the book out with a quiz that's adapted from questions that I ask patients and it takes them through the different sections of the inflammation spectrum. So the way that I educate people on in the book is there's seven main sections: looking at the gut, looking at hormones, looking at the brain, looking at the, the musculoskeletal system, the seven main sections. And then the eighth section is poly inflammation. It's the interconnectedness of the body. So, for example, the gut-skin axis or the brain-hormonal axis or the gut-brain axis. These are all different connections cause the body so brilliantly interconnected. We can kind of see the inflammation in one area can be get inflammation in another area. Through the quiz, they can find out where they're at on the inflammation spectrum. At that point, they're going to get their own toolbox of things to focus on. And then, from there, they're going to have a food plan and a nonfood list, as well, of things to consider that also can modulate inflammation or instruct inflammation in the body, too. Yeah, this definitely was a labor of love, but people are loving it. Like you said, it's been out for a little bit. And I'm excited about the things I'm seeing on social media. I didn't know. I'm just like a little like a nerd in here writing of all this health stuff, but it's cool to see people actually taking it in their own hands and doing something with it.

Jennifer: Yeah. And I would love to know, you know so much and you're connected into so many communities, if someone's listening to this and they're working on their diet right now, they've got some things we're working on, but I always feel like we ignore the lifestyle pieces. I think it's because we're like, “Oh, it's free. I don't need to do that. It's not as important.” Sometimes those things are almost more important than everything else, I feel like at times, that people can do. So is there one or two things that you've found to be really effective with your patients as far as lifestyle changes that they could implement either starting today or tomorrow, something that's really simple for them to do.

Dr. Cole: Yeah. Number one is sleep. And you're right, it's very undermined and it's not given the attention and gravity that it deserves because it's like, “Yeah, it's just sleep.” And we all know we should have good sleep, but it's really not focused on an actually given the full credence that it deserves. This is not a luxury. This is people say in jest, “I'll sleep when I'm dead.” This is not a luxury. This is a mandate on your health. And to deal with inflammation, when you deal with skin health or whatever other inflammatory problem you're going through, you have to look at sleep because that's where your body is rejuvenating and healing and calming down and repairing itself. You have to support repair mechanisms. You need to be getting proper restorative sleep. And it's not just about quantity, it's about quality as well.

Dr. Cole: Looking at what's inhibiting quantity and quality of sleep. If you have trouble falling asleep, if you have trouble staying asleep, you have to deal with it. This is not a matter of just this, “Well, I don't get enough sleep. I'm a little bit tired.” What are the far reaching implications to your poor sleep? It can be great. Just one night of poor sleep has been linked in the scientific literature to increasing that high-sensitivity C-reactive protein, that hs-CRP that we talked about. Just one night, let alone, I mean most of the people that we know. I mean when you're consulting patients, it's not a one-night deal. This is chronically years in the making of disordered sleeping. So you have to look at sleep hygiene as we call it, as I talk about. That and the inflammation spectrum. What's causing that? Or is it just poor habits? But things like, obviously, insomnia, circadian rhythm issues, people with sleep apnea, that can be a component to it as well. Or it may just be poor sleep hygiene. Or you're having caffeine too late at night. You're watching TV on your phone too late at night. All of the things, right, we're all probably all guilty to some degree, but we need to be mindful of respecting our body and using self care as a form of self respect and giving it that full gravity that it deserves.

Dr. Cole: So looking at sleep. We're talking about eight, nine hours of sleep. I mean if you're being a little bit looser, seven to nine hours of restorative sleep. We don't catch up with our sleep, and people like to think about that. It's like, “Oh, I didn't get enough sleep always, and I'll sleep more on Saturday.” It doesn't work like that. It has to be a nightly thing where you're doing the best you can with what you have access to. Some people have crazy schedules, some people have new babies, and that's the season of life. I get it. I have two kids. I know that's, for new moms and dads, that's tough sometimes. More for the new moms, normally. We need to realize that's just a season. Do you can with the season that you're in.

Dr. Cole: And then the second thing I would say would be stress. Stress and sleep are tied into each other, but really looking at stress, beyond the fluffy Instagram posts of like zenning out or meditate, to really cultivate a practice of stillness and healthy margin in your life. Whether that's a healthy margin or through relationships, whether it's toxic relationships or family members that are not healthy, whether it's healthy margins with technology, healthy margins with a bad work environment really. Just finding checks and balances in your life to create stillness and cultivate acts of stillness. Not just avoiding the stress and the toxic but also leaning into things to mitigate that, to activate the parasympathetic, the rest and digest system of the body.

Dr. Cole: Things like mindfulness. When I say mindfulness, I mean really practicing it, making it a practice. Like you go to the gym, you can't go to the gym once a month, and say it's not working. You have to really be diligent and make it weeks and months and months of cultivating a practice and strengthening that mindfulness muscle takes time. App like Headspace or Calm. You can go take a class at YWCA or something like that. And I would say really leaning into that. Or yoga and Tai Chi or just diffusing like essential oils like lavender and making your own mindfulness practice and stillness, creating sort of a sanctuary in your home, reading a book. Using tea as a ceremony, a form of mindfulness, and I think these are all things that people need to do. Those things. Sleep stress will help calm inflammation levels, too. It's not just about food. So those are some of the nonfood inflammers that I talk about in the inflammation spectrum.

Jennifer: Thank you so much for that because I like to impress upon people. I will say that's my bias is to remember that just because there are certain free things out there doesn't mean that we shouldn't take them as seriously and everybody's like, “What supplement can I do? What did with that?” And I'm like, “Hold on a second. Got to cover our bases first.” That is really important because you can take all the supplements in the world and still be incredibly sick and unhappy. I just want to thank you so much. You've got a great book. As I said, The Inflammation Spectrum is out and available everywhere. I'll put links to it in our show notes. And you've also got a guide that folks can download The Elixir Guide for Inflammation, that's available on your website?

Dr. Cole: Yeah. You can get everything at drwillcole.com.

Jennifer: Perfect. And for anybody on Instagram, Dr. Cole has a fantastic Instagram account. I always go there and I'm like, “I just need some inspiration today. I need something. And inevitably I will find something pulled out of there. I really enjoy it. So it's very positive and uplifting and I'm sure for anybody, if you're having a little bit of a rough moment had there, you will find some inspiration.

Dr. Cole: Thank you.

Jennifer: Thank you, by the way, for coming on the show. I really appreciate it and I'm excited for everybody to check out your new book. So thank you so much for joining us.

Dr. Cole: Please thank you so much.

“Skin problems do not happen in a vacuum. They are happening for a reason, and oftentimes it's an internal.”