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

For those of us with chronic skin rashes, topical steroid creams are usually the first thing prescribed. But many of us aren't given any guidelines for the safe use of these topicals, or informed about alternative treatments we can utilize.

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

My guest today is Dr. Peter Lio. Dr. Lio is 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 discuss the safe use of topical steroid creams, topical steroid withdrawal, and the use of topical B12 for skin rashes.

Have you tried topical B12 for skin rashes? Let me know in the comments!

In this episode:

• How should people use topical steroid creams?
• What is Topical Steroid Withdrawal?
• Using topical steroids on sensitive spots (e.g. eyelids)
• How do products like Eucrisa differ from topical steroid creams?
• What is PEA (and could it be good for your skin)?
• Using Topical B12 for skin rashes

Quotes

“When you put topical steroids on, your blood vessels constrict. And if you keep doing that, then they kind of rebound and dilate, which is part of why we think people with TSW are bright red all the time. Their blood vessels are kind of broken from that.” [17:50]

“B12 is crimson red as a powder and when put in this white base, it becomes pink. So we call it pink magic. And we've had it in our office for many years. And lots of patients like it. Again, it's got very modest effect, but it is very soothing.” [22:47]

Links

Find Dr. Lio online

Topical Steroid Withdrawal in Atopic Dermatitis article

To try Pink Magic, contact Dr. Lio's office HERE

Pink Magic recipe

ITSAN

Find Dr. Lio on Twitter | Facebook

104: Topical B12 For Skin Rashes w/ Dr. Peter Lio FULL TRANSCRIPT

Jennifer: Hello, everyone. Welcome back. Today's guest is a guest you may remember, who by the way has the all time record for the number one most downloaded podcast on The Healthy Skin Show. If you don't remember him, his name is Dr. Peter Lio, and he's a clinical assistant professor of dermatology and 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, and he's written a textbook on integrative dermatology and has published over 100 papers. Thank you so much for joining us again, Dr. Lio.

Dr. Lio: Thank you for having me back.

Jennifer: So today, and I appreciate that you're willing to talk about this, we are going to talk about how to use and not use topical steroid creams.

Dr. Lio: I love it.

Jennifer: And I feel like this is a little controversial because I think… And so you're the expert on this, but are there actually guidelines of how to use them according to the who's who of dermatology, or is it sort of a little bit of a Wild West still?

Dr. Lio: I would say you're right. I think that it is a little bit of a Wild West to some degree. I think there are general guidelines, but the interpretation is pretty wide open, and that's why I think you see a huge variability. I think many, many doctors and health practitioners who use steroids are pretty responsible and use them correctly, but for every five or six great people that do it right, there's a couple of folks who maybe don't or are more cavalier. And sometimes, it's well intentioned. I don't think anybody's trying to poison people. I mean, I really think they're genuinely trying to get people better. But if you're not paying attention to it, I think you can get into trouble with them more easily than people realize. That familiarity breeds too much I think comfort with them sometimes.

Jennifer: Yeah. And also too, someone else whom I've interviewed, she's a patient, has made this case that sometimes you have this big tube, and even though you're told to only use it for a certain period of time, when an itch starts happening and you start scratching, you're like, “Well, let me just get the tube of cream.” And so you think it doesn't matter that you start maybe using it a little bit more than you were directed to, and before you know it, you're using it all the time. So why don't you tell us how should someone, generally speaking, be using steroid creams?

Dr. Lio: Absolutely. I love the way you think about health and disease too, and I think that's why I really enjoy talking with you about it too. I would say that to a certain extent, steroids are going to be our, I don't want to say last resort, but they're going to be something we do if the basic things don't help. So if a new patient comes in who has itchy, uncomfortable skin, the first things we want to ask are, is there a clear trigger? Is it that they're putting a product on that's irritating them? Are they using a harsh soap? Are they letting sweat stay on after they exercise, which is irritating them? All those basic things, and for some patients, there's no doubt you can just make some small changes and get their skin better without ever having to use prescriptions. For others, it may be dietary and other lifestyle changes, so there's a little bit of that work that has to be done.

Dr. Lio: But as you get to the more severe patients or those who are really uncomfortable acutely, people are like, “Oh, I can't sleep, my skin's really driving me crazy,” then we want to help with that suffering, want to help with the disease. So we would use the steroid because they've been around for a long time. They're really reliable. I mean, I would say nearly 100% of patients will respond to the appropriate strength steroid, which is kind of amazing. There are few things like that in the world where you can count on it to work. And when used correctly, they're pretty safe. They're also accessible. Because they're pretty inexpensive, most patients can literally just go to the pharmacy and get them as opposed to the fancier new medicines where I get 6,000 letters back in a fax, and I have to do a prior authorization letter.

Dr. Lio: So all these things I think make it very easy and a reasonable first line. So my general overarching principle is we want to use them for as short a time as we can to get things clear. For most people, if you're dosing correctly, you're talking about three to five days. That's it. Three to five days.

Jennifer: Wow. Three to five days.

Dr. Lio: Honest to goodness, and you'll hear other people say two weeks. But I really think if you're needing two weeks to get better, A, you're probably under dosing it, and B, maybe you're not appropriate for topicals at all. That, to me, you're pushing the limit of too much. And then once you're better, I really want to have a backup plan. Now, if it's a very self-limited thing, you got into some poison ivy, five days, you're much better. Maybe a couple extra days if it's a really bad case. You fell on a whole thing, and you're miserable, but then you're done. So poison ivy, you got allergic contact dermatitis. You are done. You should not need steroids until next summer if you happen to fall into poison ivy again. Hopefully never again, you will learn your lesson, right?

Dr. Lio: But if you have a chronic disease, well, if you just stop cold turkey, then what often happens is two days later people say, “Well, now I'm itchy again. So what am I supposed to do now?” So the general rule would be we'd use the steroid for a certain number of days, and then we take at least that much time off. So if it's three to five days on, then we take three to five days off. If we do that, we find that most patients can keep that up very, very safely for probably, an indeterminate period of time. You could do that kind of indefinitely and still be fairly safe. I still don't like to see it equal because I think that's still right on the line.

Dr. Lio: My favorite is when people say, “I used it for a few days, and then I had two weeks of nothing. I was fine,” and then maybe a couple of days, “My arms were bugging me,” or, “My legs started getting itchy.” That to me is really safe and appropriate. As you get towards that halfway point, and then of course as you're beyond the halfway point, it's like, “Well, I used it for seven days. I was much better. And then I had two days off, and then I used it the last eight days. Then I had a day off, but then I was really… ” And I'm like, “Whoa, you're way overusing.” So that 50% mark I think is a good rule of thumb.

Jennifer: And for somebody who is using it every single day and can't seem to stop, obviously you can't diagnose a specific problem, and there's so many different reasons why people can have rashes. There's so many different reasons. If someone is at that point where they literally cannot even get any relief at all without using it every single day and multiple times a day, at that point, is there something maybe they should go back and ask their dermatologist about or even just to share that with the dermatologist that they're stuck?

Dr. Lio: Big time. I mean, I think that's why we usually will do that four to six week follow-up for almost everybody. And one of the key questions I'm asking is, “How did we do? How often did you need to use your steroid?” So if they say, “Oh, I saw you a month ago. I've only used it 10 days total,” I'm like, “Great, you're doing great. This is fine. This is appropriate. I'm going to see you again.” I'm not just going to give you 11 refills and say good luck. Still going to check in again to make sure we got this under control because what we really want to see is over time, a damping effect. I want to see the disease getting less, less, less. I want steroid use to be going down, down, down. I want overall health to be improving.

Dr. Lio: If we're going the wrong way, it's like, “Well, it was really good in the beginning, but now, it's getting worse. Can I have something stronger? Can I get more? Can you give me a prednisone?” It's like we got to hit the brakes. And we wrote this little paper. I wonder, maybe we can even share it in the notes because it's freely available. It's in Practical Dermatology, kind of a dermatology magazine, and I think it's kind of neat. We kind of talk about these graphs. So we're trying to get the word out. But as you said, Jen, it's controversial. I think some dermatologists look at this and say, “Oh, come on. Where are you basing that on? What is that? What's the science behind that?” And I would say there really isn't great evidence for a number, but a rule of thumb, just clinical experience, I feel that if we can be mindful of it, even if you don't stick to that 50% or better, being mindful of how much we're using is important.

Dr. Lio: So for those patients who are using it every day, and there are people who need it every day, to me, this tells me it's the wrong treatment for them. This just says, “Okay, I know you need it, but we're not doing you any favors by letting you use it every day or having used it every day. We want to go a completely new direction.” Again, maybe that means starting over what's the correct diagnosis here. Are there driving factors? Is it a dietary issue? Is it a contact in the environment? Do we need to go on a systemic agent? There's all these new nonsteroidal things that we can use to help, light therapy being one of my favorite things to start with and so on and so forth. So we want to be paying attention to that.

Dr. Lio: And I think in a busy clinic, you're seeing a lot of patients. If it's not your favorite thing, it's my favorite thing. It's what I'm interested in. I want to help these folks and learn about it. But if you're not, you're just like, “Oh, here's a refill. Please go. Thank you. I'm glad you're better. Keep using it. Here's 11,” and you get a one pound jar of triamcinolone, you can do a lot of damage doing that for every single day for a year.

Jennifer: Yeah. And I actually want to share with everybody who may or may not know my story, I did use topical steroid creams when my hands were flaring. So I don't want anyone to think that you're a bad person or you're doing something wrong if you do need it. I could not have gone without it. My hands would just become too devastated, and I couldn't function as a result. So I would use it as sparingly as possible. That was the warning from my dad who's a doctor, “Use it little and for as short a period time as humanly possible.” And I was like, “Okay.” The point of this conversation is not to say to be pro or against. The point is for all of us to have a conversation about how to use this responsibly if you choose and feel that this is something that you want to opt for on your journey. Because there is something called topical steroid withdrawal, so can you talk a little bit about what that is?

Dr. Lio: Absolutely. So it is a new… I would say newly recognized. It's probably been around for awhile in different forms, but I think now we're starting to recognize it. I would also put an asterisk that it's controversial. Many of my colleagues say, “It's baloney. It's not a real thing,” or, “It could be real, but I've never seen it,” which makes it really tough. You're kind of talking to skeptics about it, which is always really hard. But I think it's real. I'm pretty confident this is a real thing, and I have a group of patients who have this, and I think that there's probably something about those patients.

Dr. Lio: I think if you give topical steroids to a population, there are some people that truly you could probably use it every day and have minimal risk because I have patients who do that, inappropriately using Uncle Bob's steroid creams on the baby for two years. And I'm like, “Oh, my God,” and the kid's totally fine, and they can stop and everything. It's like, “Wow, okay.” So some people are really hardy and resistant. Other people, it seems like they can even use them pretty appropriately, or maybe even what I'm saying, that two week rule, maybe they're not even violating that, but then it kind of breaks their skin, and they really become dependent on it, and then they stop it. They go through this terrible withdrawal.

Dr. Lio: Now what we put in this little paper is we talked about what the pattern we tend to see, or at least, again, I don't have that much experience with it. Even I only have a few dozen patients that I really feel comfortable saying this is TSW, this topicals steroid withdrawal. There are many more patients that maybe fit into it. But again, we don't have a great way to diagnose it. So I'm still learning a lot about it. But they fall into this pattern of increasing use. Each time they want something stronger, they need a little bit more. That time between flare ups is actually getting smaller and smaller.

Dr. Lio: So I feel like when I see that, now I'm really trained to pick that up really in the first or second visit. I don't need to know you for two years. I just need to see you a couple times in a row. And if you're trending up, it's like, “We got to hit stop. We can't go down this path.” For those patients, I really try to avoid steroids altogether, or at the very, very least, I'll use it as an adjunct to a smaller area. So maybe that's a patient, we say, “We're going to start phototherapy because we need to get this under control,” or, “We're going to put you on,” some of the really severe cases, “cyclosporine and immunosuppressant or the new dupilumab medicine, the shot. We got to get everything calmed down from the inside. We can maybe use a little spa treatment, but my goal is to wean you off.”

Dr. Lio: So for these patients that are in withdrawal, it's really confusing to you because you would think that… Let's say you've used steroids for a few years. Well, we know they're completely out of your system. Probably within a few weeks, you probably can't detect much of it, and for sure within a few months, it's gone. But these patients will withdraw for months or years. I've had patients now who said they've been through three or five years of continuous withdrawal. And that's confusing because for me, at that point I feel they're probably not withdrawing anymore. Now, I feel like they have kind of been damaged by the steroids, and I'm worried that some of the patients will just keep waiting like, “Eventually, I'll get through this. It's like a drug withdrawal,” but I'm like…

Dr. Lio: I think if it's been more than a few months, I'm skeptical that it's going to just get better on its own. It may, and I want it to, but I just feel bad if people are sitting there suffering without any treatment. Obviously, I'm not going to use steroids anymore. I don't want to go near them with steroids. But again, there are these other things from the biologic agents to phototherapy to other immunosuppressants but also even just really good skincare. And there's kind of a movement in that group of patients to sort of avoid moisturizer. They call it moisturizer withdrawal too.

Jennifer: Yes, I have read a bit about that technique, and the pictures are hard to look at of people who go through that. I will be honest, and I'll share some information in the links about that just so that everybody listening can obviously see some photos of what folks who've gone through this look like. And my understanding too of topical steroid withdrawal is you could use the steroid even just on a section of your body, right? So it's not even full body, and yet that could trigger this full body because that's the thing, it's not just in a spot. It's a full body explosion of redness, dryness. Oh, my gosh. People are just so uncomfortable and in pain and a lot of times can't work, and it's very debilitating.

Dr. Lio: Exactly right.

Jennifer: Yeah. And one thing I'm curious about too, I've read a little bit that the other thing is we have to be careful what areas we use steroid creams on. And I've heard conflicting information, so I figured you're the best person to ask. Any thoughts on what happens when it's your face or around the eyes when it comes to that?

Dr. Lio: Yeah, I mean, there definitely are some really sensitive spots in the body, eyelids in particular. The genitalia, the skin is very thin there as well. Even all the folds, neck, armpits, those are very, very sensitive areas. We have to be careful, but we still sometimes need to use them. And one of the hard parts is we'll get these conflicting messages. We'll have a patient with terrible eyelid dermatitis. They're weeping and irritated, and their eyes are swelling shut. And we need to put a topical steroid there partly because I don't want to put them on oral steroid, right? So I'm going to try to use it just topically, which I think is definitely more conservative than putting them by mouth or by vein. It's like, then you're going to have to pump… It's pumping through your blood.

Dr. Lio: And a pharmacist was like, “Oh, my gosh. Don't put that on your face. It's dangerous.” And then the poor patient feels confused. They're like, “Well, wait a minute. My doctor, I trust this person. But now, this other trusted person's telling me this is dangerous.” And of course, it's very funny because the same person, the same pharmacist, will have no trouble filling a prednisone pack, which again literally is now pumping through the veins and arteries of your eye. We have literally put the steroid inside your eye as opposed to I'm just putting a little bit on your skin.

Dr. Lio: So again, if I didn't have to, I wouldn't put anybody on it. But in those times, I think we'd prefer to use topical steroids even in those sensitive areas. We just have to be extra careful. We want to watch the potency. We don't want to necessarily do it as strong as we would in other areas of the body, and most importantly, we want to watch the time. So a few days usually is enough for those eyes. We're not having to usually do it for even five days a lot of times. Just two or three days of appropriate strength. People say, “I'm so much better.”

Dr. Lio: And then maybe we can drop down to a nonsteroidal agent. So we have our tacrolimus, our pimecrolimus, and crisaborole, and I'll use the brand names here just because those are kind of obscure, but Protopic, Elidel, and Eucrisa. Those are three nonsteroidal agents that we have. They're not perfect. In fact, I would argue they're far from perfect, but they're welcome because if people say, “I don't want to use steroids,” or, “I can't,” or, “I've used them for a while. What else do I use,” that's kind of our entire bag of tricks outside of our natural and alternative treatments. We really just have those three topical agents. Although, I'm happy to say there's a bunch of things in the pipeline now. So hopefully in the next few years, we're going to actually have a much broader palette.

Jennifer: Yeah. And I also want to add being the daughter of an ophthalmologist that anytime you put anything on or around the eye, it has to say for ophthalmic use on the medication. So you can't just put anything around your eye because it will melt. It will go in the eye, and you do not want to end up at the ophthalmologist with your eyes burning. And sometimes, it can really injure the eye itself.

Dr. Lio: It's very true. I mean, we have to be super careful, and we really want to be careful, anything in the eye in particular. So these medicines would really just be for on the skin alone. That's a great point.

Jennifer: Yeah. And so let's actually talk for a moment about Eucrisa. I've had some clients who've opted for that because they found that… They were just got to a point where they were too afraid to use steroid creams. So what exactly is Eucrisa, and how does it differ from something like a topical steroid aside from it being nonsteroidal?

Dr. Lio: Right, right. No, but no, that's a great question. And it's a big breakthrough in a lot of ways. It came about from some really interesting chemistry that they'd been working on for more than a decade. And they found that the element boron has some very unique properties, and they were able to make molecules that were really different. Nobody had ever used boron in drug design. Usually they, I guess mostly carbon based systems, but they were able to do this boron chemistry that did some neat stuff. So one of the products they made was a cool antifungal, so it killed toenail fungus and fungus in the body.

Dr. Lio: And then they found that there was another thing that could block this inflammatory enzyme called phosphodiesterase-4, and this is, for a long time since the '80s, has been known to be important in atopic dermatitis. And eczema kind of drives inflammation, sort of imagine a little loudspeaker saying, “Come on, soldiers. Cause trouble,” whipping everybody up into a frenzy driving it. Well, steroids kind of shut everything down, right? They just close the whole system, which has some good effect because it makes you feel better quickly. But the bad effect is that it also makes you potentially susceptible to infection, right? When you suppress the whole system, everything shuts down.

Dr. Lio: What this does, it very carefully targets that phosphodiesterase enzyme and just quiets it down. It doesn't affect any of the other parts of the immune system, doesn't screw up your ability to fight infection, all those things. So by being much more targeted, it's a lot safer. It also doesn't affect the blood vessels, which is one of the key things that steroids do, which is something we think is probably related to TSW, that part of that's a vascular phenomenon. So when you put topical steroids on, your blood vessels constrict. And if you keep doing that, then they kind of rebound and dilate, which is part of why we think people with TSW are bright red all the time. Their blood vessels are kind of broken from that. This doesn't do that at all.

Dr. Lio: So that's the pluses. So targeted anti-inflammatory, anti-itch, which is great. What are the minuses, right? You don't get anything for nothing. The biggest minus is that it's pretty modest effect. It's a mild to kind of moderate sort of effect in terms of that inflammation. If you put it on hot eczema, really inflamed, many of my patients say, “Not only didn't it help that much, it burned. It burned a lot.” So stinging and burning is an important issue, especially when the skin's really hot. It's also expensive. It's a new medicine. They poured literally billions of dollars into developing it. So of course, it costs a ton of money. Right now, they don't have a generic. So all those things work against it unfortunately. But for the right patient, it is a lifesaver.

Dr. Lio: So I'll often use topical steroids for a few days, get things better. When they're better, they can switch to the Eucrisa. And a lot of my patients are like, “Okay, this actually is great. It doesn't burn now. Now that my skin's better, we took the edge off.” But it's actually keeping them better. Especially for hands, I'm finding it really helpful. And it almost never stings on the hands, so that's a real godsend for those patients. But many patients have tried it and didn't like it. And a lot of dermatologists are kind of soured because like, “It's expensive. I couldn't get it covered for the patient, and it didn't work that well.” So it's kind of a niche drug.

Jennifer: And I wanted to ask you because I know we talked about the PEA. Can you just share with people what is that if they've never heard of it?

Dr. Lio: Yeah, that was in that cannabinoid discussion. So one of the natural cannabinoids, or sort of derivatives of that hemp plant and in the marijuana sort of family tree, is that PEA, which is another anti-inflammatory compound. And it's been featured in a couple of different products over the years. The most recent one that was actually a prescription barrier device that you could actually write a prescription for and patients could use it. I don't even think it's on the market anymore, but it was called Atopiclair. So Atopiclair had PEA, and there were a couple other moisturizers that now have it. And it's cool. It really does show some anti-inflammatory effect. It's probably even weaker still… If steroids are the strongest, and our Eucrisa's maybe kind of in the middle, this is real modest. But again for certain patients, it could be just enough maybe to keep them out of trouble or just enough to control some of that inflammation.

Dr. Lio: That's kind of my interest in natural medicine too. Can we find things? Maybe they're not as good. I'm not going to argue. We're not going to go head-to-head against steroids, fine. But we don't need to either, right? We could use a steroid for a little, but then can we have things that'll help keep things calm. So that is definitely something that's kind of neat.

Jennifer: That's awesome. Well, I like to give people options. I think that's important because I didn't know what other options there were. I was just told Vanicream, topical steroid, and Vaseline. That was about it.

Dr. Lio: In defense of whatever poor dermatologist we're ripping on right now, there wasn't that much stuff before. And so finally, we have some new options. When I got into this area about 11 years ago now, that really kind of was it. And we just had so, so few things. Now, we have a couple of other things, and I've also kind of tried to bring in more and more natural stuff. So in the natural domain, anti-inflammatories that we can use as steroid replacements or steroid kind of extenders, we could use it a little bit, and then put those steroids away for a while. How do we extend that time? So one of the things I love is vitamin B12, topical vitamin B12. I don't remember if we ever talked about it.

Jennifer: I don't think so. Do tell. Do tell.

Dr. Lio: Yeah, this is kind of an interesting story. So when my daughter was little, she had moderate atopic dermatitis, kind of irony of ironies. She also has a food allergy, which really stinks, and that really doesn't run in our family. So I don't know where that came from, how that all appeared, but it just did. And I didn't want to use too much steroids on her either. I used some, get her under control. But if we needed more, I was like, “I really want to give her time in between.”

Dr. Lio: So I'd come across this vitamin B12 topical compound that seemed to help. And actually, it really looks like some drug companies were studying it because the studies are beautiful. They're 100s of people. They're randomized, controlled, double blinded. It's like, this is quality evidence. In the natural world, we don't get these because these are expensive to run. So a nice hemp oil company doesn't usually do that. They don't have… I mean, these are not even $100,000. These can be millions of dollars of trials. You've got to sell a lot of $9 hemp oil on Amazon or something to pay for that. It just doesn't happen. But a drug company, part of the reason the drugs is too darn expensive is because the regulatory burden's high.

Dr. Lio: Anyways, I saw these papers, and I'm like, “How do I get this?” So I'm Googling around trying to find it. Couldn't find it. A couple of weird sketchy sites, I'm like, “I don't want to put this on my kid.” So I called a compounder in Chicago who does lots of cool natural stuff. He actually is a perfumist. He does perfumes and natural oils, and so he's amazing. So I said, “Ted, can you do this?” He's like, “Well, yeah. It's dead simple. I mean, I can get the B12 powder. I'll put it in a really nice natural, a shea butter base for you.”

Dr. Lio: And we did this, and it turns out… So B12 is crimson, crimson red as a powder. We put it in this white base. It became pink, so we call it pink magic. And we've had it in our office for many years. And lots of patients like it. Again, it's very, very modest effect, but it is very soothing. And for some people they say, “You know what? When I do the pink magic, it actually lets me go far longer. I can go two full weeks without needing a steroid.” So that's something.

Dr. Lio: Another thing that I'm really interested in for kind of, again, maintaining that is there is a plant extract called cardiospermum, and cardiospermum plant extract is in… There are a couple of products, and there's one product you can get at most drug stores, and it's good. Some people like it, but the actual cream base is really crummy. There's preservatives and junky. So I feel like some people it would help, but others it would irritate. So I don't love it. So I talked to a friend of mine who has a moisturizer company, and I was telling her this, “I'd love someone to get cardiospermum.” And she's, “Let me get back to you.”

Dr. Lio: I kid you not, just in the last couple of years, she said, “I'm going to work on it.” And she said, “I can't find any good supplier, and there's one supplier in India, but I don't really like their stuff. So I'm going to grow it for you.” And I'm like, “Okay, call me. Let me know.” I kid you not. This summer, she sends me pictures of these gorgeous plants all over the place. She has a special greenhouse area to grow. She's like, “It's growing like mad.” She's like, “I'm going to have a crop. I'm going to put this together for you. And you can give this to your patients.” I'm like, “Amazing.” So stay tuned cardiospermum. That could be something really big. And I think we're always looking for stuff kind of like that.

Jennifer: And so I know people are going to go, “Wait, the pink magic.” So is that available for people to purchase or…

Dr. Lio: It is. It is. We do have a version at our office which people can call, and we can ship it to you. It's very safe. You can also, if you Google it, my name will come up because we've talked about it for the National Eczema Association. And we have the formula, so you could have a compounding pharmacy, or if you have a person like Ted who puts stuff together naturally, they can put it together for you. It's very, very simple. I mean, literally it's 0.07% vitamin B12 powder by weight in whatever moisturizer base you want. And then I actually list out the full recipe, the whatever proprietary cream that they studied in the research paper, so you can actually see all of that. We'll put the link maybe in the notes too because I'll send you this.

Jennifer: Yes, because I know people would love to learn about that. I think I had seen a talk that you had given maybe where it was mentioned, but I didn't fully understand what it was about. So I'm really glad that I asked you this.

Dr. Lio: Kind of cool, right? Yeah.

Jennifer: I didn't anticipate us going here, but this is really cool stuff. That's what this is about. It's like, let's share the ideas and help people get better. So, oh, my goodness, mind blown yet again. Every time I talk to you, you blow my mind. I'm sure everyone listening to this is going to love this episode. And so, you are in private practice, so we'll have all of your information below so that people can contact you. And then, I mean, you're one of my favorite guests, so of course we'll probably have you come back for something else sometime. But I just want to thank you so much for not just being so interested in so many things and genuinely wanting to help patients everywhere to get a solution so they can live a better life, but also your willingness to come and talk on these topics and share about it. It's so wonderful. I and I know everyone else listening really appreciates it.

Dr. Lio: It's my pleasure. Thank you so much for having me.

Jennifer: Absolutely.