142: Psoriasis 101: What You Need To Know w/ Dr. Raja Sivamani


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Psoriasis is a condition that is frustrating to have, and often frustrating to treat as well. My guest today is going to dive in to different forms of psoriasis, why getting a correct psoriasis diagnosis is important, and how psoriasis can affect other systems in the body.

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My guest today is Dr. Raja Sivamani, a board-certified dermatologist who practices at Pacific Skin Institute.

He is an Adjunct Associate Professor of Clinical Dermatology at the University of California, Davis and Director of Clinical Research and the Clinical Trials Unit. He is also an Adjunct Assistant Professor in the Department of Biological Sciences at the California State University, Sacramento.

Dr. Sivamani engages in clinical practice as well as both clinical and translational research that integrates bioengineering, nutrition, plant science, cosmetics, and skin biology. With training in both Allopathic and Ayurvedic medicine, he takes a holistic approach to his patients and in his research.

Join us as we talk about psoriasis: different types, how it's diagnosed, and how it affects other parts of the body.

How do you manage your psoriasis? Let me know in the comments!

In this episode:

  • Overview of what psoriasis is from an integrative dermatologist
  • Psoriasis + psoriatic arthritis — What's the difference?
  • Different forms of psoriasis
  • Thoughts on scalp psoriasis
  • How psoriasis impacts other organ systems (like your liver + joints)
  • Can weight loss improve your psoriasis?
  • Testing – What's important to monitor?


“The most common form is known as plaque psoriasis and that's where you get what are known as big plaques, basically these big red scaly, in many cases, very thick plaques that develop on the body that tend to occur on the outside of the arms, along the elbows, the knees, but they can go anywhere, on the back, chest.” [4:09]

“Scalp psoriasis is a challenge and if you only have scalp involvement, that's where it becomes a challenge to say that it's psoriasis because there are variants of seborrheic dermatitis that can be very severe that can also scale a lot. There's actually an in between diagnosis, Jennifer, called sebopsoriasis where it's very thick, it's way too thick to be a seborrheic dermatitis, but you don't see the psoriasis anywhere else on their body.” [8:11]


Find Dr. Sivamani online

Healthy Skin Show episode 076: What You Need To Know About Acne, Accutane & Antibiotics w/ Dr. Raja Sivamani

Jennifer's appearance on the LearnSkin podcast: An Inside-Out Approach: The Role of Nutritionists and Nutrition in Healthy Skin

Follow Dr. Sivamani on Facebook | Instagram | YouTube | Twitter

142: Psoriasis 101: What You Need To Know w/ Dr. Raja Sivamani FULL TRANSCRIPT

Jennifer: Thank you so much Dr. Sivamani for joining us back on the show and especially because you wanted to talk today about psoriasis, which I really appreciate because I have had a little bit of trouble getting people on the show to talk about psoriasis and I think part of it is that a lot of people feel like psoriasis is frustrating and frustrating to get results with. So my thought was that maybe you could talk about how there are different forms of psoriasis, what is psoriasis, what is psoriatic arthritis, and then there are other forms of psoriasis. So maybe we could start with a good general overview of this condition.

Dr. Sivamani: Yeah, it's always a pleasure to be on with you, Jennifer. I love your podcast. I think you're doing a great job of getting the word out there.

Jennifer: Thanks.

Dr. Sivamani: My thoughts around psoriasis is that psoriasis is a chronic condition and it's a challenging condition. It has so many variations on how it shows up on the body and it can be so debilitating to someone because the psoriasis can be widespread, it affects very cosmetically sensitive areas like the arms and the legs, but people don't realize that it also affects other areas that we can talk about that can actually take away your ability to interact socially and can really affect confidence. So maybe part of the reason people aren't talking about it is it is such a devastating condition, but we have great treatments for it and great approaches now.

Jennifer: Is it possible for someone to start off, is it that they start off with psoriasis and then could possibly transition to psoriatic arthritis or could you literally just start with psoriatic arthritis and then transition or kind of all of a sudden psoriasis emerges? Like what's the deal with those two issues?

Dr. Sivamani: This is such an important question because there is no set rule on how things have to happen. Psoriasis, just as an overview, it's a chronic inflammatory condition and it's considered auto inflammatory. Some people think it might be autoimmune, but we haven't figured out what the autoimmune target is. Many times when we say something [inaudible 00:02:10], we have a target and we say, okay, so this is what is the cause or this is the reason that it's developing because there's a certain maybe factor in the body that the body's attacking itself against. But that's not what happens. We don't know exactly what it is, but we do know that there's a subset of the immune system known as the TH17 cells and there's a whole pathway of the immune system that is in overdrive. So we know it's an auto inflammatory condition.

Dr. Sivamani: Now to go back to your question about do you need to have the skin come first or the joints come first? Psoriasis is one of those conditions where it could go in either direction. It's easier for us to wrap our head around psoriasis when we see it on the skin because that's what we're used to seeing. We're used to hearing about and visualizing what psoriasis looks like on the skin. But it is not only because it's a chronic inflammatory condition, there's also an inflammatory component in the joints and you can definitely get the arthritis first and that can be very challenging because when you first get the arthritis it can have a very mixed picture where you're not sure is this really psoriasis or is this another autoimmune or auto inflammatory joint problem or what's going on.

Dr. Sivamani: Many times you clinch the diagnosis when the psoriasis comes to the surface on the skin. But yeah, you can go in either direction. You can either have psoriasis on the skin first and then extend to the joints or you could have it in the joints first and then extend to the skin. And sometimes you get psoriasis in the skin and you don't ever end up developing anything in the joints. So there's not a one rule that fits all, so to speak.

Jennifer: And if we were to go back to then just psoriasis in and of itself, there are different forms of psoriasis. Can you tell us what are the major buckets of those forms are and is there some real difference between them that you feel is clinically significant?

Dr. Sivamani: Yes, absolutely. So there are several forms of psoriasis. The most common form is known as plaque psoriasis and that's where you get what are known as big plaques, basically these big red scaly, in many cases, very thick plaques that develop on the body that tend to occur on the outside of the arms, along the elbows, the knees, but they can go anywhere, on the back, chest. It tends to not affect the face central so much. Maybe along the hairline, definitely gets into the scalp. So that's plaque psoriasis and another variation of psoriasis can be guttate psoriasis, which is a slightly different variation. Guttate just means small drops and so what you can get is instead of these huge plaques, you'll get these small little drops of sort of those scaly, what we call patches or papules where you just get a bunch of these all over.

Dr. Sivamani: And that's a unique form of psoriasis. We think in most cases, if someone's been exposed to strep throat, we think that the immune system comes in, it reacts to the step throat, in many cases they get treated with antibiotics, which is obviously actually very important when you're treating strep throat for many reasons, but the immune system reacts to the strep throat and then in people that have a certain predisposition, not everyone, when people that have the immune system that's prime to predispose them, that same immune response to strep throat can then react and become guttate psoriasis. Now, one of the interesting things about guttate psoriasis is that it responds really well to what's known as phototherapy, light therapy, where you can use a medical grade Light box. It tends to occur a lot in younger folks like teenagers and 20s.

Dr. Sivamani: So yeah, plaque psoriasis, guttate psoriasis. There are several other variations, so I'll just go through them just pretty quickly. Another one is inverse psoriasis. Inverse psoriasis means that it affects the areas that are in the skin folds, so the armpits, the groin area. Sometimes if there's a neck fold that's occluded a lot or if people are a little bit bigger and they have the stomach that's kind of folding over the very lower part of their abdomen, then you can get some in there and sometimes along the creases and the creases of the knees. So that's another one. And again, these aren't mutually exclusive. Someone can have plaque psoriasis and inverse psoriasis.

Dr. Sivamani: And then another factor is pustular psoriasis where you can get these puss bumps that are all over the body. That can sometimes happen. Nail psoriasis, you can have involvement of the nails, which can be debilitating if your nails aren't as strong. And you can imagine, we use our nails for a lot of things, we take them for granted. And then not that it's a specific variant, but genital psoriasis, a lot of people don't realize when someone comes in with psoriasis, it's really important to ask them about their sexual history. And it's really important to as physicians talk to them about, well does it involve their genitals? Because that can be very socially debilitating and it's so empowering for a patient to hear that you care about that aspect because you can treat it.

Dr. Sivamani: But you would never know and sometimes patients are too embarrassed to show even the physician when they come in. So it's important to ask. So that's not an exhaustive list, but I just wanted to give a flavor of the different kinds of psoriasis that are out there and why it's so important to get that diagnosis right so that then when you think about treatment, you can make it as effective as possible.

Jennifer: Yeah, and one of the common complaints that I hear from people is that for example, those with scalp psoriasis, which can be really frustrating.

Dr. Sivamani: Very frustrating.

Jennifer: Especially because it can impact the quality of your hair and then you've got flakes in it. I've had a few clients where some dermatologist thought that they had seborrheic dermatitis. Others said that maybe they had psoriasis and they couldn't get a straight answer and they were struggling with a lot of itching. And then eventually it turned out to be psoriasis. Is there anything specific or any thoughts you have on psoriasis when it ends up on the scalp?

Dr. Sivamani: Scalp psoriasis is a challenge and if you only have scalp involvement, that's where it becomes a challenge to say that it's psoriasis because there are variants of seborrheic dermatitis that can be very severe that can also scale a lot. There's actually an in between diagnosis, Jennifer, called sebopsoriasis where it's very thick, it's way too thick to be a seborrheic dermatitis, but you don't see the psoriasis anywhere else on their body. So the notion of this diagnostic called sebopsoriasis is the fact that it is very thick, looks very akin to psoriasis, just on the scalp. Now regardless, the treatments are so important, like you say, I mean, people can't wear certain clothing colors. It's constantly itching, different climates flare it.

Dr. Sivamani: But when it comes to that diagnosis, sometimes it's not a straight, hard and fast diagnosis. If you have psoriasis everywhere else then it's easy to say, okay, this is scalp psoriasis. But sometimes there becomes this in between land, depending on how thick the scale is, how widespread it is. Sometimes a diagnosis can flow between, not usually seborrheic dermatitis, but between sebopsoriasis and psoriasis. But it's definitely important to have someone take a really good look. And also when it comes to treatment, you can't use ointments. I've seen some patients been given ointments before and like, how are you going to get that in unless you're bald, you know?That's not-

Jennifer: That is true. Yeah, that's got to be a really difficult, I mean, I just know from clients, I mean that has usually been one of the biggest complaint areas is the scalp and the frustration in trying to alleviate the itching and the lesions that they have. And it's interesting too, a lot of times people don't realize that there's other connections in the body when it comes to psoriasis. Because it's not just a skin problem, at least from everything I've read, I'm like, oh my gosh, it's connected to this, and this, and this. And a lot of times people aren't fully aware of that.

Jennifer: So I thought you'd be a great person to ask this, what other areas of the body, if you have a diagnosis of psoriasis, what other areas of the body do you need to be considering that this could also either maybe there's connections in causing flares or maybe it kind of moves back and forth. One impacts the other and the other impacts the psoriasis. And so it's sort of this vicious cycle that you get into.

Dr. Sivamani: So I think getting that diagnosis right is so important, and here's why. Psoriasis can have many mimickers and one of the mimickers, and when I say mimickers, you can easily get a misdiagnosis if you're not in the right setting to get that diagnosis correct out of the gate, is a condition called nummular dermatitis. And that can look like psoriasis because it's round and it shows up on the body. And then there are other conditions that could be a bit more chronic and have a different take that can also look like psoriasis.

Dr. Sivamani: So I think it's really important to make sure you see someone that's just used to, so I would highly recommend making sure you get the diagnosis right by a dermatologist. I love integrative care, but I think just making sure you go and see someone that's a dermatologist to get that diagnosis right, and here's why. If it is psoriasis, like you said, it has other implications for the rest of the body because psoriasis in and of itself is not just a skin condition. It is an inflammation that goes through the entire body, the joints get affected and you can have really bad joints, psoriatic psoriasis to the point where you can get mutilated joints if it's not treated well and treated appropriately or treated quickly. And so that needs to be addressed.

Dr. Sivamani: And then the cardiovascular risk that is associated with someone that has psoriasis is a real one. And what I mean is if you have psoriasis and it's left unchecked, untreated, you have this constant inflammation that's going on and we now have studies showing that your cardiovascular risk for a cardiovascular event goes up. You have increased risk and by and large, a lot of people with psoriasis are young. So having an increased risk of cardiovascular events when you're young can be quite devastating if that ends up affecting someone when they're early in their life cycle and they may have children or whatnot. And so I think it's important that that diagnosis is gotten accurately. And also like you said, that we realize that there are other connections to the rest of the body.

Jennifer: Yeah. And the other thing I want to ask you too about this is, yes, I agree with you getting an accurate diagnosis is correct, but what is the best way? Is it that you just go and show them the rashes and someone will say, oh, it looks like psoriasis or would it be best if someone, when they go to their dermatologist, they ask for say a biopsy? What's your opinion on that?

Dr. Sivamani: Yeah, biopsies are an interesting thing. Psoriasis is a clinical diagnosis and it really requires that expertise of looking at the skin and saying, okay, this really fits with psoriasis. Now the problem with biopsies is that many times when someone has classic, classic psoriasis and you do a biopsy, the biopsy can actually be equivocal, just depending on what stage of inflammation that particular spot was where the biopsy was taken. And that's not even necessarily an error of the practitioner. Sometimes we'll do a biopsy on psoriasis, clear cut psoriasis, but we need it for some other, some insurance company wants something to be a verified or whatnot. Those days are actually, I mean, that doesn't happen that often, by the way. Usually the clinical diagnosis is the clincher.

Dr. Sivamani: But when you do biopsies, it can tell you that it's quote it's a clincher, but if when you do biopsies it, it can tell you that it's quote a psoriasis, a form dermatitis, or it says it's psoriasis, but sometimes it can give you something else that can lead you astray and it's the clinical diagnosis that really matters. And I did also want to say you can also get psoriasis on the hands that can be quite debilitating and those can be a tough one. If it's just the hands, sometimes it's hard to differentiate between hand eczema and hand psoriasis. But luckily some of the treatments crossover to be similar between the two. But a biopsy is not the end all be all way of diagnosing psoriasis, it's the clinical exam. So you do have to show someone and they do have to look at your skin entirely.

Jennifer: And actually, lets kind of circle back because I want to touch on the liver connection with psoriasis. I think that is so important because our liver does so many critical things to help support proper health in the body. Can you talk a little bit about what happens or what can happen when you have psoriasis and you just go, well I'm just going to manage it, manage it, and you're not really paying attention to the rest of the body. You're not maybe going in regularly to get comprehensive metabolic panels or looking at other liver markers. What could happen to your liver?

Dr. Sivamani: So with psoriasis it's really important to realize that because it's an inflammatory condition, it's going to have general inflammation, but there are some associations that are really important. So when it comes to weight, by and large, a lot of psoriatic patients and people that struggle with psoriasis in one form or another, not all of them, but many of them are overweight and many of them are dealing with weight related issues. And what happens is that combo of inflammation and also the increased weight, we see a little bit more of an inflammatory load to the liver, either with fatty liver or just liver inflammation. There is low grade liver inflammation, that is present not on all patients with psoriasis, but with a lot of people with psoriasis you do see this increased inflammation of the liver.

Dr. Sivamani: Now it's interesting to go to other traditions like Ayurvedic medicine, we talk about the three doshas, just really briefly, Vata, Pitta, Kapha. Psoriasis is a condition that's very heavily imbalanced in the Pitta Dosha. And Pitta is a representation of a lot of inflammation and its house organ is the liver. And you'll see this in other traditions where treating psoriasis includes some form of liver support or at least getting people to think about losing weight to lessen the burden on the liver.

Jennifer: That is one of the most interesting things. You had mentioned to me before we started talking that there is an interest, you found some interesting research about the connection between weight loss and psoriasis.

Dr. Sivamani: Yes. Yeah, this is something that I talk to all patients about now. So there was a meta analysis and what a meta analysis is is basically you take several clinical studies and you put it all together and you combine the statistics in a very structured way so that you can now just instead of looking at one study, you can look at a group of studies and come up with an overall conclusion. And what they found was that regardless of what treatment you go on, whether it's a pharmaceutical or whether you're using some sort of supplement or some sort of topical therapies or oral therapies, if you can lose weight, and if a patient with psoriasis, a person with psoriasis can lose weight, they have a much greater chance of having an improvement in their psoriasis regardless of what treatment you go on.

Dr. Sivamani: And they don't really particularly pinpoint what is the best way to lose weight. In this study what they showed was if you can lose weight, that will automatically increase your ability to respond even to medications. And so when I talk to my patients, I tell them that strategies to lose weight are very important and that includes nutrition. That is a really important key because I think in the Western diet, a lot of people don't realize that there are so many factors that can optimize. And Jennifer, you would know this like the back of your hand, but there's so many things that people have taken for granted that might not be great ways to approach nutrition. And then once you empower them that way, then get them into exercise and movement and whatever it is and that becomes a lifestyle to then maintain good weight. But that is so important because even medications respond better.

Jennifer: Yeah. And do you, out of curiosity, do you look at liver values for your patients or do you feel like, I think because that's always a question, it's like where do you go to get all of this care? And obviously we want to build a team, but what do you recommend? Like does a dermatologist run some of these tests to make sure the liver is doing okay or do you usually send them back to a primary care doctor or do they go to see an endocrinologist? Like who would oversee that to make sure that if say they did have some sort of fatty liver issue going on or were just trying to get a baseline, where do you start with that?

Dr. Sivamani: Yeah, I can tell you that we do it. Just because we're trained to do a lot of lab testing and with psoriasis, some psoriasis, Jennifer, I will tell you, is head to toe covered completely. But I do want to tell you a separate story with psoriasis I think that'd be really important. But before we jump into that and digress, yes, we do the testing. I mean, I do the testing because many cases if someone with psoriasis is coming and sitting in front of me, they may already have issues with metabolic issues. So their primary care's already checked some of their blood and in which case we'd go ahead and take a look at it.

Dr. Sivamani: But if not, then I do check their liver test. Especially if I'm thinking about maybe some medication in the future or talking about diet and they ask me, hey doc, how's my lipid panel looking and this and that. If it's not in there, I actually take primary responsibility as the dermatologist that's taking care of them for psoriasis, which we know is a metabolic disease to then check that stuff because I think it's important that we get that full picture when we're talking to our patients.

Jennifer: And so for any maybe doctors even listening to this show, because I know that we do have practitioners that tune in. What type of, for the liver part of this, what type of, you said the lipid panel, is there anything else that you're looking at just to take a look at that connection and make sure that the liver is functioning properly?

Dr. Sivamani: Well, the lipid panel's more if they already have some existing metabolic disease or if especially if they have some family history of cholesterol issues. But what I look at when I'm trying to look at the liver is the liver function test, the LFT. And so there you can look at factors like the AST and the ALT, which are both enzymes that are released from the liver and you just want to be sure they're in a normal level. Sometimes if they're a little bit elevated, we always recheck them just to be sure it's not just some one-off aberration, but if it tends to get really high, that's where I actually will go back to the primary care and I'll tell them, hey, I'm noticing that yes, we're treating them for their psoriasis and we try to bring in the care team and say, okay, who else can help with this person?

Dr. Sivamani: If they're having issues with the liver being elevated, then we may send them to eventually back to the primary care to assess whether do they need to go see another specialist to help with this aspect. Is the liver really inflamed or not? If they want to have a question about, okay, I see I have these changes in my blood tests and now I want to think about what I can do from a lifestyle perspective, then I will try to reach out to folks that are either naturopathic doctors or nutritionists to then start talking to them about, okay, what's now the next step that I can do to empower myself? So when you ask about care teams, absolutely. But I think that if you're going to check something for the liver, the LFT's really important as a first step.

Dr. Sivamani: Now I don't think there are studies saying that every single person should get an LFT, but if a person with psoriasis is overweight or they're really struggling with a sense of fatigue or they seem to be just overwhelmed with inflammation, I think it's worth checking just to be sure you don't miss something there.

Jennifer: Perfect. And one more quick question. There are a lot of people with psoriasis that have been bombarded online about do this diet, do that diet, cut out night shades, do AIP, all this stuff. Do you have any quick thoughts on diet? Because I feel like that's a whole other almost like a can of worms we could open. But do you find that there is one diet that seems to help with psoriasis from your practice and clinical experience?

Dr. Sivamani: Yeah, you're very right in that there's so many different aspects to diet that people are given as advice. And I don't think there's any one thing that works. Now, one thing I do tell my patients though is to cut out red meat as much as possible because I think red meat really adds to the fat intake that's coming in and going through the liver. And I do think that red meat is inflammatory as well. So I try to move them more towards a plant based diet because that's been shown even with the gut microbiome to be helpful. And it's been shown in general to be anti-inflammatory as long as they're not carb bloating. Make sure you actually are eating healthy in that regard.

Jennifer: I'm just curious, so it would be your advice then if hey, if you're moving more toward plants, don't necessarily go, oh, I'm just going to eat like loads of rice or loads of beans.

Dr. Sivamani: Yeah, exactly.

Jennifer: You have to be mindful of the carb portions on the plate.

Dr. Sivamani: Yeah. And so I'll tell you the two things I tell people across the board. If they want to take out night shades, that's fine. But the two things I tell people is cut out the red meat and cut out the dairy because I think both are not necessary as you get older. Because the problem with red meat is it's such a load of fat and it's going to go right through the liver and we know it's already inflammatory to the colon and whatnot. And the second thing with dairy, especially when it's cow's milk dairy, I think it's such a spiker of insulin and it's just going to make it harder to lose weight. And I know a lot of my patients that cut out dairy start to lose weight easier.

Dr. Sivamani: And as I mentioned before, if you can lose weight whatever way you can, it helps the psoriasis in the long run. And so I start with those two and then delving into the details, whether you're comfortable with the Ayurvedic perspective, other nutritional aspects that are important. I think there's not a one size fits all, but those are the two things I do tell everybody that has psoriasis.

Jennifer: Perfect. That is so helpful. I love hearing your perspective on things, especially because of all the work that you do. I mean, I am just such a huge fan as you know and I really appreciate too you having me on, I was on your podcast before, so we'll have to link that up in the show notes. It's so great to be able to collaborate back and forth together and help support people more and more so that that way they can get the answers that they're seeking, no matter whether they're a practitioner or they're a patient. It's great that we all can work together to help people find results at the end of the day and live a better life.

Jennifer: And I want to make sure everyone knows where to find you. They can find you over at learnskin.com and you also have an incredible platform to help practitioners, specifically doctors, but other practitioners can also take some of the coursework that you have, which is truly amazing because it's all about integrative dermatology and you've got a great integrative dermatology symposium once a year. Do you want to just say anything about that?

Dr. Sivamani: Yeah, this is definitely one of the passion projects that we've been working on. So as you mentioned, learnskin.com, we have the learnskin podcast and as part of learnskin, the whole goal is that we get an integrative conversation around not just dermatology but health in general, but our focus is dermatology, but when you do anything integrative it becomes beyond any one organ. We do run the Integrative Dermatologist Symposium and I do want to just also talk about the new and greatest thing that we're doing, which is the integrative dermatology certificate program.

Dr. Sivamani: Right now we have it open for practitioners that are really focused in on dermatology, dermatologist, but we are going to open it up, but the idea is that you come in and get this very focused, intensive training program over six months where you can learn about multiple different diseases, multiple different aspects to how you can approach health, whether it's mind body or whether it's energy medicine or whether it's the microbiome and really focusing on evidence and clinical case discussions. And we're hoping that by doing this we really continue to build the community towards what I think is the best way to do things is integrative approaches to health care so that it becomes the true form of medicine and the actual way we do medicine.

Jennifer: Perfect. Well we'll put all of your links in the show notes that way people can go and find you and check out this program, which I was super excited to see announced and I'm also looking forward to attending the Integrative Dermatology Symposium in the fall. So for anyone listening-

Dr. Sivamani: Yes, October 23rd.

Jennifer: Yeah, so if anyone's listening, if you are a practitioner, this would be a great opportunity if you're interested in this to attend something like this, to continue learning and connecting with like minds who are out there really wanting to support their patients and clients as best they can from all different perspectives. But Dr. Sivamani, I really appreciate you coming back to the show and I hope that we can have you back again some time.

Dr. Sivamani: Oh, anytime, Jennifer, just let me know. I love talking about this stuff, of course, as you know. And it's a pleasure to be on your show, I love the conversation that we have. Thank you so much.

“The most common form is known as plaque psoriasis and that's where you get what are known as big plaques, basically these big red scaly, in many cases, very thick plaques that develop on the body that tend to occur on the outside of the arms, along the elbows, the knees, but they can go anywhere, on the back, chest.” [4:09]

Jennifer Fugo, MS, CNS

Jennifer Fugo, MS, CNS is an integrative Clinical Nutritionist and the founder of Skinterrupt. She works with women who are fed up with chronic gut and skin rash issues discover the root causes and create a plan to get them back to a fuller, richer life.

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