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176: Dealing With Recurrent Skin Infections w/ Dr. Peter Lio

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Do you struggle with recurrent skin infections, like staph or strep? In today's episode, my guest and I discuss what can cause recurrent skin infections, the difference between a skin rash flare and a skin infection, and ways to reduce skin infections.  

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

My guest today is Dr. Peter Lio, a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine.

He received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, he received formal training in acupuncture.

Dr. Lio has written a textbook on Integrative Dermatology and has published over 100 papers.

Join us as we talk about the possible causes of recurrent skin infections, and steps you can take to reduce them.

Have you experienced recurrent skin infections (e.g. staph or strep)? Let me know in the comments!

In this episode:

  • Can you get a skin infection from products you are using on your skin regularly?
  • More hygienic ways to use skin products
  • Considerations if you get recurrent skin infections (like staph infections)
  • Should you seek treatment for a skin infection?
  • What are other skin infections?

Quotes

“I really think there is something to this concept that people who are heavily colonized, if that's how we want to call it, it's not just a benign bystander. It is actually doing bad stuff to the skin.” [16:07]

“Such a big portion of my practice is recurrent staph infection and staph colonization…One of the big triggers I think is having multiple family members who are colonized.” [5:33]

Links

Find Dr. Lio Online

Healthy Skin Show ep. 001: How to Protect & Strengthen Your Skin Barrier w/ Dr. Peter Lio

Healthy Skin Show ep. 037: Nickel Allergy And Eczema w/ Dr. Peter Lio

Healthy Skin Show ep. 104: Topical B12 For Skin Rashes w/ Dr. Peter Lio

Healthy Skin Show ep. 136: Alternative Solutions For Rosacea w/ Dr. Peter Lio

Healthy Skin Show ep. 004: A Groundbreaking Approach To Treating Atopic Eczema w/ Dr. Richard Aron

Healthy Skin Show ep. 106: What The Heck Is Eczema Herpeticum? w/ Abby Lai

Call Dr. Lio's office at (312) 995-1955 to order Pink Magic cream

Follow Dr. Lio on Twitter | Facebook

176: Dealing With Recurrent Skin Infections w/ Dr. Peter Lio FULL TRANSCRIPT

Jennifer: Thank you so much for joining us again, Dr. Lio. I really appreciate you coming back on the show.

Dr. Lio: Thank you for having me. I'm excited to be back.

Jennifer: I know, especially for today's topic. So to give you guys some context, it had occurred to me at a certain point that it could be possible that when we have certain skin infections. We talk a lot about staph when it comes to eczema, but people with psoriasis can also get staph infections. And when you're using a lot of creams, we have this diverse microbiome on our skin that could cause the potential of reinfection through your products that you're putting on your skin. Is that possible? So I thought the best person to answer these types of questions, to help all of you maintain healthier skin and hopefully avoid potentially reinfecting yourself, was Dr. Lio. Okay. First question, can you get a staph infection, or a strep infection, or whatever type of skin infection from products that you're using, either on a daily basis or maybe it was an antibiotic cream, or a steroid cream, or something that you've been prescribed?

Dr. Lio: Absolutely. I think the answer is a resounding, yes. Part of the issue is of course, well formulated products have preservatives in them, in part to keep the growth of this kind of bacteria down, but also to keep the growth of fungal growths and molds, things like that down as well. And we know from some of my early days, we were mixing stuff up in the kitchen, trying different things and you realize that stuff that is very natural nature takes it back. Suddenly, all of a sudden you have a big growth of mold on it, or you have stinky bacteria growing in there. So you realize, okay, [inaudible 00:01:55] why companies put preservatives in there. It's not just for fun or to poison people. In fact, I think it works against them a lot. A lot of preservatives, they can be an allergen and an irritant.

Dr. Lio: We wish we didn't have to. And the purpose though is really to keep that growth down. Now, this is magnified many-fold when you have somebody who already has some bacteria on their skin. So maybe even if they package it sterilely, if it's perfect when they put it in there, you reach in with your fingers… This is particularly for jars, you reach in with your fingers, you take some of the cream out, you put it on your skin, maybe where you're either at truly infected or at least carrying staph. Because we know a huge portion of our patients with sensitive skin, atopic dermatitis, damaged skin. We know the microbiome is abnormal, and there probably is an overgrowth of staph, aureus in particular, but as you said, strep can also be on the skin. Then you put your grubby finger back into that pot.

Dr. Lio: You do that again. Now, you've inoculated it. Now, for some things, I think if there's enough preservative and there's not too much bacteria, you'll be okay. You can get away with that. But it's a little bit of a Russian roulette. And I've had patients who keep getting infected, and then I finally say, “listen, let's get you fresh jars of everything.” Because they bring them in and they look kind of grubby. And I'll say, “when we reach in, instead of using our fingers, maybe we can use a clean spoon. So you can spoon some out and then put that in your hands, put that on.” So the only thing that goes in there as a clean spoon. That can really help. Then the next step is, can we find products that can get around this? One of our tricky spots is pumps. A lot of patients love pumps. I love pumps, they are so convenient. But historically, most of the things that come out of a pump are really lotiony, their liquidity.

Dr. Lio: For sensitive skin and eczema, we tend not to want those. But there are some newer pumps that actually are durable enough to let creams pump out, so pretty thick. And the most exciting technology I've seen, a couple of French companies have done this, where they actually produced the moisturizer in a sterile environment. They package it and hermetically seal it with a one-way air-tight valve. And I remember it was just… Honestly, in the last couple of years, this is still new enough that we were at a little meeting and someone was saying, “well, creams can't have no preservative, because creams have water and water can grow bacteria and stuff. So it needs a preservative.” A couple of us knew, so we turned and we said, “actually, that's not true.” This was a dermatologist. We said, “it's not true, because this company and other companies have done this hermetic sealing. So, they can actually make a cream or even a lotion with no preservatives.” Which is really exciting.

Jennifer: Wow. That is cool. That is really cool. So for anybody listening, who now they're putting their hands in the jar and they keep getting staph infections. This could be a problem… With steroid creams also be a potential issue, because they're not an antibiotic, they're not an anti-microbial per se, right?

Dr. Lio: Correct. Absolutely. Steroids would be one moisturizers for sure. But honestly, even as you say it, potentially even an antibacterial thing. If you have like a compounded thing that has a low amount of antibiotic, you put enough staph in there and it will overgrow to the point where it could just be colonizing a part of it or some part of the jar. Then again, every time you put your hand in there, you're just putting more and more bacteria on your skin.

Jennifer: What do you say to someone who does get recurrent, let's just say staph infections, just for simplicity sake? And it's again and again. You'll give them an antibiotic or I don't know whether you prefer topicals or oral medications for that. Do you also have to worry about the clothes that you're wearing or the sheets of your bed? Are there other areas where we need to be concerned?

Dr. Lio: Absolutely. And it's amazing. Such a big portion of my practice is recurrent staph infection and staph colonization. You're right, there are a number of ways it happens. One of the big triggers I think is having multiple family members who are colonized. We know that we carry staph in our nose. The anterior part of your nose can be a place where you carry staph. Now, for many healthy people, they're fine. It doesn't bother them. Their body keeps it at bay, it walls it off and it protects you. But every time you wipe your nose or touch your face, you could then give it to somebody who maybe isn't as able to fight it off. And we've had families where we have so many staph infections after awhile, that we say, “okay, everyone needs to decolonize.” And we'll do things like antibacterial washes.

Dr. Lio: We'll have them put the mupirocin, a topical antibacterial in their nose, three times a day for a week. I'll even have them take, everybody goes on probiotics. We just need to like do a big reset, because it's not good for the environment. It's not good for the patient to keep needing antibiotics. But with staph infections, you can't mess around. If you let it go too far, you can get really sick. You get hospitalized, you can be in all sorts of trouble. So we have to take it seriously, but we don't want to be abusive of antibiotics. Of course, we know every time we use that, we're potentially making super-bacteria that are then able to resist those antibiotics.

Jennifer: Do you ever do a culture of the nose? Because it was interesting you mentioned that, and I know Dr. Julie Greenberg has also mentioned staph can be in the nostril area, and I've read that elsewhere. Can you talk a little bit just about that? Because I think that's an interesting thing that oftentimes gets overlooked.

Dr. Lio: Absolutely. We culture both the skin and the nose, and sometimes I'll even culture multiple family members when they're in the office. If the parents are there, I'm going to say, “I'm going to check you guys too.” Again, especially in these really tough cases. And so many times we find that multiple people are colonized or just growing staph aureus from that nose swab. I will say that the goal is to eradicate it, and we think we can do it sometimes. But I will tell you that some of the studies are a little disappointing, all the stuff we do, from antiseptic cleansers, and [inaudible 00:07:32] in the nose and all this stuff.

Dr. Lio: Many times they reset back to carrying staph again. So we think, part of the problem is that some people are just susceptible to it and staph is so pervasive in our environment now, if you are one of the folks who's a little bit weakened to it. And usually we think there's people that have leaky skin, their skin barrier is a little bit damaged, a little bit sensitive to it, susceptible to it, that they keep getting it again and again. So for those folks, it can be really a struggle. It's an uphill battle, always trying to make sure [inaudible 00:08:00] stay on top.

Jennifer: Does staph die when you launder your clothes? Because I know sometimes with women who would have recurrent yeast infections, they'd be like, “look, you got to get rid of those yoga pants.” After a certain point, the yoga pants could be a problem, because the yeast has colonized the pants and you probably got to get rid of them. Is it possible too that your clothing could also be an issue after a certain point or your bedsheets? Maybe do you have to launder with a certain temperature?

Dr. Lio: Yes. I think that's a great point. I think clothing, bed sheets, fomites around the house, they definitely can carry it, especially if we're not washing it regularly. Most people don't wash their bedsheets… I figured, most people don't even wash it once a week. Maybe sometimes even two or three weeks go by and you haven't washed it. Absolutely. But no, I do think that as long as we wash it in nice hot water with a detergent, you probably get all of it out. It's not a very tough bacteria. So outside of strange situations where maybe it's formed like a biofilm or something, I think you'd be okay just washing it. But you're right, things around the house can carry it. And again, pets, dogs can also carry it too. You give your dog a kiss or the dog licks your face, and again, you're passing it back and forth.

Jennifer: Oh boy. All right. So we got… Pets is a problem. If you have a staph infection right now, would you recommend that sheets… Especially if it's a full body, it's a big problem. We've got a large area covered in staph or strep or something like that. Would you say every day the sheets should be changed and laundered to help try to get rid of that?

Dr. Lio: I think that would be awesome. It is a big ask, doing that kind of laundry every day is a lot. But I think that would be great as we're treating it. And I think that's why we're so adamant about taking a daily bath or shower. And you'll hear this controversy, sometimes particularly old school pediatricians will be like, “no, bathe less frequently, bathe once every two weeks or something.” I think there was a really a good wisdom to that in the old days, because many of the cleansers or frankly, even if you just go and water by itself, water kind of strips your natural oils.

Dr. Lio: So it could actually be a net negative for those patients. But now, we're using super gentle cleansers. Often I like ones that are oil based, so I feel like we're actually adding good stuff when we wash. But most importantly, we're rinsing off all the staph or some of the staph at least. Then we can lock in the moisture with a good moisturizer. So I think the net effect is now positive, and they're not too much data on this, but a recent study really did show, they called it the wet method. They said bathing twice a day and moisturizing was much better to bathing once every two weeks, which was really neat.

Jennifer: What type of cleansers? Because I just heard you mention oil-based cleansers. What is that?

Dr. Lio: It's been so neat to watch this, and I'll preface this by saying that many of my colleagues might kind of roll their eyes. A lot of my colleagues are like, “look, just pick a gentle cleanser. They're all pretty similar.” Ultimately, I agree, I'm not trying to be controversial. But I find that… First of all, I like looking for little niches. Which is my favorite? Which is the best? Which one might've get just a few percentage points better? Because I think we all know, sometimes the difference between needing a steroid, needing a big gun medicine, needing an antibiotic and not can be just a little tiny bit. So if I can take all those little gains, using the best of the best for all these little things. Sometimes you add up to be enough that you don't need to do the bigger thing.

Dr. Lio: That being said, there's been a kind of a revolution with cleansers. The first revolution was with synthetic detergents. And I would say that like [Cetaphil 00:11:28] brand is one of the ones that's been around for a very long time. If you look at the history, I feel like it's more than 50 years or something. They were the first to kind of get away from a soap, because soap really starts with a fat and then it uses a really strong alkaline lie to render it. Those are nice, but they're really harsh on your skin. They may do a great job of pulling fat and ripping things up. We don't want that on our skin, even though in a way they're kind of natural, but they're also pretty hard our skin.

Dr. Lio: So these synthetic detergents where the first round, much gentler on the skin. But now we're in a new era, where I think we're seeing people actually formulate the cleansers with an oil. And there are a bunch of different brands that are on the market. If you punch into one of your search engines, oil-based cleanser, you'll find some really neat options. I like some of the French ones. There is a French one that I like a lot. That's just really gentle. It's a little pricey, but not ridiculous. I love it, because I feel like after you wash, you're like, “Oh my gosh, I'm actually more moisturized than before, it left a little oil behind.”

Dr. Lio: So I think those can be really great. Now, a bunch of brands have them. I think there were some early adopters, but now I think you can… Cerave has a version of it. Eucerin has a version, they're all really good. I don't think you can go wrong. Mustela has one. [Event 00:12:37] is the one I was referring to too. There are all these good ones. And I work with these companies in different ways, so I don't want to appear biased. But I just think they're all interesting things to think about. That being said, then if we moisturize right after, I think we really get a great net positive effect on the skin.

Jennifer: Okay. The thing is with skin infections, I feel like people… And you could correct me if you have a different perspective on this. But I feel like a lot of times people try to muscle through a skin infection, thinking that it's a “flare,” and they're suffering for an unnecessary amount of time trying to manage a flare. When in reality they have a skin infection. Do you find that that sometimes is the case?

Dr. Lio: Yeah. I think you've hit it right in the center of the controversy right now in atopic dermatitis world. So first of all, I completely agree with you. I think you're right on. If you really have a skin infection, you really want to get it treated. And I'll tell you, this is not trying to incite fear, but I actually had a patient when I was back in Boston, healthy, robust, 18 year old guy. He was a football player for high school, had really bad eczema. I mean, just really bad, struggled with it a lot, got tons of skin infections. One day got a skin infection so bad, he was in the hospital and actually got a blood clot from it. It was so bad, it actually created a clot and he had a stroke.

Jennifer: Oh my god.

Dr. Lio: He basically became septic, that's really scary. Now, admittedly, that's super rare, super out there. But we really thought it was like, yes, he had staph in his blood and that created a septic state. And then he got crazy. That kind of stuff scares the heck out of me, even though it's super rare. But even for the regular infections, maybe smaller, not that scary, they cause pain. They can spread to other people. They can keep going on to become chronic. So I think it is good to get it controlled. I think no one would argue with that. Where it gets more interesting and controversial is this concept of colonization. A lot of our eczema patients, they're not really infected. They don't have a fever. They're not in necessarily pain. They don't have a high white blood cell count. If they went to the hospital, it'd be like, “well, your skin looks terrible, but you don't have an infection.”

Dr. Lio: You can culture their skin and they'll grow tons of staph. But what we would call it, we'd say, “okay, you're colonized. You're just colonized.” The bacteria is taking residence on your body. Kind of like the people with it in their nose, and it's not necessarily doing anything bad. That's kind of, I would say the standard interpretation of what's going on. But in the past five or six years that I've been really deep diving into eczema and focusing on it, I've really changed my view on this. And I think we're coming around to it. So it's increasingly less controversial, which is kind of refreshing. But when I first started talking this way, people were like, “he's a little bit out there.” But it's based on the work of this guy, Dr. Richard Aron. I can't remember if we talked about him before.

Jennifer: And I've had Dr. Aron on the show.

Dr. Lio: Okay, great.

Jennifer: I think it was episode four or something like that.

Dr. Lio: He's amazing. He's a trailblazer. And it's fun, because… And I I'll briefly tell the story. But when I first learned about his plan, which is to put a little bit of antibacterial in a compound for the eczema patients, even if they're not frankly infected, because he really believes staph was playing a big role. I fully, openly, and it's in writing. I've written it up, that I rolled my eyes and I was like, “come on, this isn't going to do anything. This is placebo level. This is not going to help.” But I gave it a try. A patient asked me… A patient of mine said, “can we please try it?” And I said, “yes,” it's not going to hurt you. It's very diluted. They called me a week later and they were like, “this is the best thing you've ever done for me.”

Dr. Lio: I was flummoxed. I'm like, “wait, what? What did I give you again?” I had to go back in my books. I'm like, “the Aron thing.” And then another patient asked me, and another, finally I said, “okay, there is something to this.” So I really think there is something to this concept that people who are heavily colonized, if that's how we want to call it, it's not just a benign bystander. It is actually doing bad stuff to the skin. And now we're learning more and more about it. There is a beautiful paper showing some of the different toxins staph makes on your skin. There's one called Delta toxin. It actually fuels inflammation. It can damage the skin barrier, all of these kinds of things.

Dr. Lio: So I think the long… It's a very long answer to the question, which I really think our conception of staph as a driver of disease has changed in just the 15 or 20 years I've been in practice. It went from just being a quiet bystander that, yeah, we see this, to now saying, “okay, this is potentially a pathogen that is driving the condition for at least some people.” Obviously, it's not the cure all. And now we're really… There's a race for how do we get rid of it without abusing antibiotics, without causing trouble, without making it so that we now have resistant super bugs everywhere. And that's a hard question.

Jennifer: That is. That's one reason why I wanted to have this conversation about how are we potentially… And it's not blaming anyone. I want to be very clear about that. I know sometimes living with skin issues, and sometimes saying, “well, if I did this, it must be my fault.” We're not trying to blame anyone for anything. We just want to educate and share with you all, some ways in which we can perpetuate an unhealthy cycle. And that's sort of the idea of saying, “okay, how can we have a better regimen, a better hygienic regimen around using pots of cream and different things.”

Jennifer: But I also think it's important for people to know when to go get help. And that's where I oftentimes find… Eight out of 10 initial calls that I will get for my practice, I can tell just from listening to the person talk and the symptoms. I'm like, “you need to go see a dermatologist ASAP for that. That sounds like an infection.” “No, I'm managing and it's just a flare.” I'm like, “no, I don't want to hear from you again until you go see a doctor.” Sure enough, they have an infection. As a dermatologist, what's the point at which someone needs to get help and ask if there's an infection going on, it's not just a flare?

Dr. Lio: I think it is a little tricky, but I'll tell you some hard lines where I would say, “you should never get to this point without going to see somebody.” If you have a fever, 100%, no arguments. Or feeling feverish at all, feeling that that kind of feeling where you feel sick, you have to go in. If you have skin pain, pain is a really important sign. If you're itchy and uncomfortable, that's one thing. But if you touch your skin and say, “it hurts.” You really need to go in. I would even say that is on the border of the derm emergency. We have to make sure we know what's going on. You may be infected. All of these kinds of things are really important to rule out. And I also think that if something's going on and on. It's one thing to have a bad day or two, you're like, “my skin's kind of bad.” But now we're on day four, day five. Maybe you don't have a fever. Maybe you don't feel that sick, but your skin's not healing.

Dr. Lio: One of the reasons may be that you are infected or carrying enough staph that you just can't get over this hump. And that's really important to get checked. It doesn't have to be a dermatologist. I know there's a long wait. Sometimes my patients often express a lot of frustration before they… Hopefully once they get to see me, then I'm much more accessible, but getting in to see us can be hard. So of course, see your pediatrician, see your primary care doctor. Even see an urgent care and just say, “Hey, look, my skin's hurting me. Can you check it? Can you do a culture? Do you think I need an antibiotic?” Most physicians and healthcare practitioners are pretty well equipped to at least make that decision. And at the end of the day, I'd much rather over-treat at least once or twice, I don't want to make a habit of it. But I'd rather over-treat and give somebody an antibiotic who didn't need it rather than, God forbid, miss that, and then they're really sick.

Jennifer: Is burning… I've had some other people talk about how their skin feels like it's on fire. Like it's just burning. That would be a part of that pain scenario.

Dr. Lio: I think it really could be, yes.

Jennifer: Okay. So it's not just staph, there are other potential organisms that… We've talked about demodex mites. We talked about that in regards to rosacea. But what are some other potential infections that people could get on the skin aside from staph, that people don't talk about as much?

Dr. Lio: You also mentioned strep, that can be a skin infection, and I've seen some bad strep pustulosis. Pustulose that are pretty uncomfortable. We can get pseudomonas infection. Sometimes you'll hear it called hot tub folliculitis. So people go into a hot tub at a resort or a hotel, and then there's bacteria in the water that loves the hot water. It goes in their hair follicles. They get itchy, painful, puss bumps all over. Then of course there's fungal infections. Malassezia, we know is one of the guys that plays a role in cradle cap and also seborrheic dermatitis, but it can also be a big driver of a certain subtype of atopic dermatitis we call head and neck eczema. And they're kind of overloaded with it. Then of course there's a herpes virus. For our eczema patients and truly anybody with kind of damaged skin barrier, instead of just getting a cup of cold sores, because their skin barrier is abnormal, it can spread out.

Dr. Lio: We call that eczema herpeticum, and that can be actually dangerous. You can actually get really sick. You can die from it. It's rare, but it's quite an emergency. So when I'm listening, when a patient calls me, I'm listening for pain, fever, discomfort, or if they say, “gosh, this one patch won't heal.” And I've had those patients come in, and sometimes bacteria, but sometimes they say, “Oh my gosh, you have eczema herpeticum on your legs.” And we need to treat that. So that one requires not only antibiotic, but an antiviral, like acyclovir of your valacyclovir. And we can treat it. But if they're sick, they got to go in the hospital. I'll give them IV, anti-virals for a few days-

Jennifer: Wow.

Dr. Lio: … to make sure… It's pretty spooky.

Jennifer: That's serious.

Dr. Lio: It's quite serious.

Jennifer: This is why everyone, we need to ask for help when… If you feel like you are working with someone right now, and they're not listening to you, find someone else who does listen. Dr. Lio, you have a practice, you're in Chicago?

Dr. Lio: Yeah, right downtown in River North.

Jennifer: Goodness, I've had a lot of clients go see Dr. Lio, he and his associates are very responsive and very… You guys listen, I like that. You really listen and take stock. Every single client I've had is like, “Oh my gosh, here's the first time that I didn't feel like I was looked at sideways. You guys really listened and helped.” It's important to have someone on your side who can help you when you're… Like, Hey, we have recurrent staph infections or whatever type of infections we have, but also too, making sure to dig like you do. That's so fascinating that you also look at the family, the environment, their products. You really do dig through their life to help them sort out the re-infection process, because it is important to stop. And then also too, I want you to share once more. We had talked in a previous episode about the Pink Magic Cream, and you guys make that and sell that through your office, correct?

Dr. Lio: We do, yes. We've had that for a number of years. That was originally made for my daughter, when she was a little baby with eczema. So that's a non-steroidal use of topical vitamin B12. And it's this really cute pink color, because B12 is kind of Crimson red, when you mix it up it's pink. That's been a very nice treatment. It's very mild, but it's quite soothing. And for some patients they say that can actually extend or even potentially replace the use of a steroid.

Jennifer: That's awesome. We'll make sure that we'll have that information in the show notes, so that if people are interested in also getting that from you, or if they want to contact you about setting up an appointment, they can do so. We'll have everything in the show notes.

Dr. Lio: That'd be great.

Jennifer: I really appreciate you coming back. Thank you so much for being so generous with your wisdom, your knowledge and your experience, and also just being so open minded. It's incredibly refreshing. I think that's probably one reason why you have… Out of all the interviews that you and I have done, your interviews are at the top of the charts of all time downloads. Because people just really appreciate your approach to things. It means so much, not just to me, but to everyone who listens. So, thank you so much.

Dr. Lio: It's my pleasure. If I can help people, that makes me really happy.

Jennifer: That is awesome. Well, thank you so much for being here and hopefully we'll have you come back again sometime.

Dr. Lio: I'd love it.

“I really think there is something to this concept that people who are heavily colonized, if that's how we want to call it, it's not just a benign bystander. It is actually doing bad stuff to the skin.”


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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