This episode is bought to you by Quell — to help support rebuilding healthy skin from the outside-in + inside-out!
Take 10% off your next order! Use promo code QUELL10 at check out — Get started HERE!
– – –
Have you heard that if you're going through Topical Steroid Withdrawal (TSW), that you just have to wait it out?
“Just give it time… time is what heals.”
But when you say that to someone who's years (3 or 5 or even 8 years) into TSW, that statement starts feeling like a bitter pill with no hope in sight.
Some practitioners (like myself) are finding that there are things you can do to better support your body as it goes on this journey. There's certainly no silver bullet solution as we still do not have enough research to know the best way forward.
But if you could help your system not be as reactive, that may be a win to make things more manageable for you.
Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android
My guest today, Dr. Julie Greenberg, is a licensed ND who specializes in integrative dermatology.
She is the founder of the Center for Integrative Dermatology, a holistic dermatology clinic that approaches skin problems by finding and treating the root cause.
Dr. Greenberg holds degrees from Northwestern University, Stanford University and Bastyr University, and received advanced clinical training at the Dermatology Clinic at the University of Washington Medical School and at the Pediatric Dermatology Center at Seattle Children’s Hospital.
She is also the Program Chair of the Naturopathic & Integrative Dermatology series on LearnSkin.com, a learning platform for integrative health care professionals.
Join us as we discuss whether TSW really is just a “waiting game” or if there are other things you can do that can help.
I'd love to know if you have tried any of the tips that Dr. Greenberg has shared in this episode — Let me know in the comments!
In this episode:
- What is happening to someone going through Topical Steroid Withdrawal (TSW)?
- Testing that could be helpful for TSW
- Concerns over vastly different potencies of different types of steroid creams
- Is TSW the ONLY thing you need to worry about at the moment (if you're experiencing it)?
- Collagen supplementation for TSW
- Thoughts on adaptogenic herbs — do they have a place to support your body through TSW?
Quotes
“You have to think if you put that hydrocortisone on 600 times, that's equivalent to one dose of betamethasone or clobetasol. Some of them are 150 times, so it depends on the strength of the steroids. The surface area that you're using on, how frequently and how long have you used it. And of course, one thing that we forget to mention is that we have higher systemic absorption of these topical steroids on compromised or broken skin.”
“We know that that red, inflamed skin is vasodilation. The vessels have been constricted for so long artificially with the topical whatever you're using and now they're also bouncing back. So we get vasodilation, which means that the blood vessels are over-expanded, over dilated. We get this blood influx, which is why they have that red, inflamed skin and moisture leaking out of their skin and they're oozing.”
Links
Healthy Skin Show ep. 132: What is Topical Steroid Withdrawal? w/ Kathryn Tullos
Healthy Skin Show ep. 174: When Topical Steroid Withdrawal Gets Complicated
Healthy Skin Show ep. 203: Licorice + Topical Steroid Exposure – Should You Be Concerned? (PART 1) w/ Dr. Carrie Jones
Healthy Skin Show ep. 204: Licorice + Topical Steroid Exposure – Should You Be Concerned? (PART 2) w/ Dr. Carrie Jones
225: Topical Steroid Withdrawal (TSW)- Is It Just A Waiting Game? w/ Dr. Julie Greenberg FULL TRANSCRIPT
Jennifer:
Dr. Greenberg, I am so excited to have you come back. Every time you are here, you drop a ton of knowledge bombs and then we always have such a great conversation. So I appreciate the time and especially on such an interesting topic where there still is not a lot of research.
Dr. Greenberg:
I'm so excited to be here again and to talk with you about this. I think as you and I agree, this is really an important topic and there's a lot of misinformation out there. So I hope you and I together today can help get some good information out there on TSW.
Jennifer:
Yeah, I feel like unfortunately, there's all of this fear around food, around a lot of different things, which I understand because people do become highly reactive. I would love for you to maybe kick off this conversation with what do you feel are some of the missteps of how we're currently addressing or thinking about TSW in terms of trying to get better?
Dr. Greenberg:
I think the first thing that people are completely ignoring is that the underlying condition that got them there, which is usually eczema, that's the reason that they were using topical steroids or calcineurin inhibitors like tacrolimus or PDE4 inhibitors like EUCRISA. That underlying problem with eczema has not been addressed and solved, so you have two problems when you have TSW. You still have eczema and now you have TSW. You have to address them both. The TSW is really an immediate crisis and depending on the severity of the TSW, it can be quite severe. People can get hospitalized, not be able to work, lose relationships, so we need to do some things to address the immediate TSW on hand. But you cannot forget about that eczema and that underlying condition that got you there.
Dr. Greenberg:
For me, if anyone has heard me talk on your show before, I'm going to be banging the drum on the gut because it really is the gut disfunction that's driving the eczema and you haven't dealt with that yet. With my TSW patients, I really make sure that they understand we are treating two problems here. Yes, we are immediately addressing this TSW, I want to make you more comfortable and make life more livable in your skin because I know how horrible it is. But we're going to also have to treat that eczema and that underlying gut dysfunction. It really takes that two pronged approach to get TSW under control in a reasonable amount of time and hopefully, get rid of it for good.
Jennifer:
I agree with you 100%. I alluded to this in another podcast that I did, it was just a solo podcast of me talking about like, “Hey, I think sometimes there's things that make TSW a lot more complicated, that draw out the amount of time that you're dealing with symptoms. Blaming it on TSW, when in reality it's not TSW. It's actually something else.” That's what I've found in clients that I've worked with, is there oftentimes are still those underlying root causes, but then you have this other problem that is hugely painful. You have a lot of shame around it, there's a lot of anger, there's a lot of fatigue because you can't sleep. Any number of things. It's a living hell going through this.
Jennifer:
We all know topical steroid use and obviously combining that with steroid use in other forms is exacerbating the relationship that your body has with cortisol. That's really problematic, so what is the way that you look at at least just the TSW piece? What are your thoughts on just that specifically in terms of cortisol and the adrenals?
Dr. Greenberg:
Yeah, that is a great question and I still think there's a lot of untangling we have to do to try to figure this out. For eczema, which we may or not get to, I do gut testing, I do a stool test and a urine test to figure out what the gut dysfunction is. For my TSW patients, there's a third test I do. It's a hormone test and it specifically measures their cortisol at four points throughout the day. We have to remember cortisol is not a hormone that stays the same all throughout the day. It's a diurnal hormone, so it's our get up and go hormone when we wake up in the morning. Cortisol's supposed to shoot up, give us motivation to get up and start our day. And then it starts going down in the afternoon because melatonin needs to start to rise and that's going to take over and we settle down at night and go to sleep.
Dr. Greenberg:
You can't just do a one spot cortisol test, it's really not going to tell you anything because it changes throughout the day. The one that I use is a urine test, it's dried urine. You urinate on these strips of paper at four points throughout the day and then there's additional morning testing called a cortisol awakening response that you can do. But sometimes I'll just do the four points throughout the day, which is the first minute you wake up, you pee. Two hours later, you pee. About 5:00 p.m. and then about 10:00 p.m. I want to see how someone's cortisol is running throughout the day. This looks at active cortisol and then metabolized. I want to see what's happening systemically with their cortisol. That's one piece of it.
Dr. Greenberg:
The other piece is I've tried to do a bunch of research into how topical steroids affect cortisol and I found some interesting stuff. On the one hand, there are cases of, and this is a fancy word, iatrogenic Cushing's disease. Iatrogenic means that the disease was caused by medication. Cushing's is a disease of the adrenal system where you have too little cortisol being produced. We know as doctors, that if we give someone oral steroids like prednisone, we can absolutely shut down their adrenal glands because the body's always trying to be efficient. It's looking around and going, “Oh, my gosh. I have so many things I have to manufacture. How are we doing on cortisol?” If we take something like an oral steroid, it's called a corticosteroid, it's basically giving your body cortisol. The body is smart and it's like, “Where did all this cortisol come from? I don't know, but cool.” It's like finding a bag of money and it gives the signal to the adrenals like, “Hey, shut down production of cortisol because we don't need you.”
Dr. Greenberg:
We know that if we give someone oral corticosteroids for long periods of time, we have to taper them. We have to give the body time to recognize, oh, wait a minute. What happened to all that cortisol? It's gone. Oh, snap. I guess, adrenals, you're onboard again, got to fire it up. So the adrenals are like, “Okay, let's get this factory back into gear.” Then they will start to produce the cortisol and you can taper them off of the prednisone.
Dr. Greenberg:
For some reason, most of the medical community denies that topical steroids can do this. Like, “No, we don't absorb the cortisol. It's not enough.” Well, the truth is there are many factors to that. What kind of strength of topical steroids are you using? Hydrocortisone is considered the mildest form and that's what our body produces. But if you go up to something like a betamethasone, that can be 650 times the potency of hydrocortisone. Yeah, it's a super high dose.
Jennifer:
I'm just sitting here with my mouth gaping open. That's a lot.
Dr. Greenberg:
It's astounding. You have to think if you put that hydrocortisone on 600 times, that's equivalent to one dose of betamethasone or clobetasol. Some of them are 150 times, so it depends on the strength of the steroids. The surface area that you're using on, how frequently and how long have you used it. And of course, one thing that we forget to mention is that we have higher systemic absorption of these topical steroids on compromised or broken skin. Well, where are we putting these topical steroids? On compromised and broken skin. You're not putting it on healthy skin, so of course you're going to absorb more of that topical whatever it is, as we talked about.
Dr. Greenberg:
Topical steroid withdrawal is a little bit of a misnomer because it can happen as a result of topical steroids, oral steroids, topical calcineurin inhibitors. Again, that's tacrolimus, pimecrolimus, and PDE4 inhibitors like EUCRISA or Crisaborole is the name. We really need to come up with a new nomenclature than just TSW, but your listeners should know that I'm talking about all of these things. We are putting all of these topicals on compromised skin, we are going to absorb more of them systemically.
Dr. Greenberg:
Most of the medical community refuses to acknowledge the effect on the adrenal glands of these topical steroids in the same way that no doctor would deny it from oral steroids like prednisone. But there is literature, I've done research of these induced adrenal insufficiencies like Cushing disease, from topical steroids. It's not that it's not out there in the literature, it's just still not well accepted amongst dermatologists. There are some, it's interesting because I was attending a conventional dermatology conference a couple weeks ago. Of course, it was virtual. But one of the doctors, the dermatologist was talking about rashes and we have as doctors what we call a DDX or a differential diagnosis. He was saying when you're seeing a rash, keep in mind these other possible problems that it could be. And he listed topical steroid withdrawal and I nearly fell out of my chair because you don't hear that many dermatologists recognizing TSW as a legitimate and real condition. So it depends on the dermatologist, but this was at a conference, he was talking about eczema and brought up topical steroid withdrawal as a legitimate possible alternative to skin problems that you're seeing.
Dr. Greenberg:
That was wonderful. But then in the next session there was another dermatologist who was complaining about his patients who didn't want to go on topical steroids for whatever reason, because a lot of dermatologists now are getting pushback from patients. Like, “I don't want to use a topical steroid. This can harm me or my child and this is obviously not addressing a root cause because we're not deficient in topical steroids.” His advice was that he tells patients that topical steroids are natural because we produce cortisol.
Jennifer:
What?
Dr. Greenberg:
That's a little disingenuous. Yeah. It was a very interesting juxtaposition from two dermatologists with completely differing opinions obviously, of topical steroids and what might be legitimate and how to approach patients. But that was quite interesting from session to session. I don't think it's fair to tell patients that topical steroids are natural because that is not exactly the case.
Jennifer:
No. No, it's not. I mean, I'm going to admit I'm not a doctor, but if it's manufactured, it's not natural. It may be similar, but it's not natural. And to deny that everything has an impact, both positive and negative, I mean, you could literally eat yourself into a coma if you eat pounds and pounds of Swiss chard or kale every day because of the goitrogens in them if it's raw. It's very rare, but it has happened. No one's going to argue that kale and Swiss chard are bad for you, but to act as if there's no potential harm from using a medication at high levels for years and years and years, I just think we have to find a different way, that's just my personal opinion. Also, having worked with clients, they've been tested for every weird, rare disease because of all the oddball symptoms that present as a result of it. Then ultimately being handed more steroids for their issue, which in reality was really a TSW problem in the first place.
Jennifer:
I think we're at a turning point. I know it feels slow for many who are advocating for change, but it is starting to happen. I mean, that's impressive that at least someone mentioned it in a conference. We want to also too, one reason I invited you here is because I think that it's important as a community since there's no standard right now. It's basically practitioners who agree or believe in this and are working with this population to be able to share what's actually working and what we see. Because there are not studies to really look at here to say, “Oh, this herb or do that.” We have to think outside of the box and be creative.
I want to preface this, of course, you guys who are listening know, this is not medical advice. These are just recommendations, these are suggestions that you bring back to your own practitioner to discuss. You do your own research, we are not suggesting by any stretch of the imagination that anything we discuss here today, this is your next step. It's not. It's just information only. It's important that we share that because TSW is complicated, it can also be complicated when we assume maybe you have a flare up and it could be a skin infection. You do have to be careful of that.
What are some of the first things that you find have been helpful for your patients who are struggling with TSW? Are you going in and actually supporting adrenal function or what are some of the things that you find that are helpful?
Dr. Greenberg:
Yes, thank you for saying that about this is not medical advice. I really want to stress that people need to work with a provider. But in my experience with TSW, yeah, I told you I do that test to test the cortisol. I have found that in most of my patients, their cortisol is high. Now, I am not sure if this is a rebound effect and interestingly, I've done research. We have cortisol production in the skin and so the steroids are basically suppressing the cortisol. I don't know if this is a bounce-back feature or what is going on, but by the time patients get to me and they're in topical steroid withdrawal and they have that red, inflamed skin, on my testing their cortisol tends to be high.
Dr. Greenberg:
We know that that red, inflamed skin is vasodilation. The vessels have been constricted for so long artificially with the topical whatever you're using and now they're also bouncing back. So we get vasodilation, which means that the blood vessels are over-expanded, over dilated. We get this blood influx, which is why they have that red, inflamed skin and moisture leaking out of their skin and they're oozing.
Dr. Greenberg:
I do that test and then based on what I see, I use adrenal support. As a naturopathic doctor, I'm also a registered herbalist in the American Herbalist Guild. I really rely heavily on herbs for my protocols. There's a lot of what we call adrenal adaptogens. An adaptogen is a hard concept for Western medicine to grasp, but there are herbs that if your adrenals are too active, it will calm them down, and if they're underactive, it will fire them up. That's an adaptogen, you can give it an either situation and it's going to help your body do what it needs to do. Again, it's really a hard concept in Western medicine, but it's very common in the herbal world, in Chinese medicine, Ayurvedic medicine and naturopathic medicine. There's a world of herbs that I will use for the adrenal support. Some classic adaptogens are things like Ashwagandha, Holy Basil, Rhodiola, Schisandra, there's a lot of them. And again, you should work with a provider and not just start taking herbs.
Dr. Greenberg:
But I definitely start with adrenal support specifically for my TSW patients based on the lab work and what I see on their cortisol. Is it high all the time? Is it tanking? What kind of support do they need? I find that it's really pretty helpful.
Jennifer:
Can I ask you a question about that? I don't know if you're aware, but there are some circles within the TSW community that think that all adaptogenic herbs are actually steroids.
Dr. Greenberg:
I mean, I'm guessing that they're thinking of licorice…
Jennifer:
Licorice is one and then I've heard things about Ashwagandha, it has an action similar to a mineral corticoid. I mean, none of this is, from my understanding, based on actual research. But there is a legitimate fear. I'm going to assume the answer's yes, but I just want to hear you say it because I think they need to hear it. Especially somebody who's feeling really confused and read stuff on somebody's blog who has no experience except their own. Do you find that the adaptogenic herbs make TSW worse or can they help?
Dr. Greenberg:
No. I find that they make a huge beneficial difference. They have a huge positive impact, but again, this is not to say nobody should go out and just start taking Ashwagandha. This is why I test their cortisol and I actually see what's happening and then I use a formula that's based on their needs. We do have adrenal formulas for people who have very low cortisol, where we're trying to get the adrenals to kick it up a notch. Then we have formulas where people are just at basically redline, pumping out cortisol all day long and we need to calm down the adrenals. So yeah, you want to be using the right herbs, the right blends, the right amounts for your specific situation and so you need a trained herbalist. Somebody who's trained in herbs and someone who understands what's happening in your specific cortisol.
Dr. Greenberg:
But I find that they are pretty foundational to the TSW component of the plan that I'm doing because we know that the adrenals are involved. I mean, other things are involved too, but there's no doubt that the adrenals are involved, so why wouldn't we want to go in and test and support them?
Jennifer:
I agree with you. My experience has actually been very positive, including adaptogenic herbs. So the confusion and the backlash around this has been very confusing to me. I want to say this with all due respect too, because I recognize that people who are listening to this, there are some people who are really big advocates within the TSW community and know that we stand with you. We are on your side. But there are some things that have been really misconstrued. I think part of this, maybe you can speak to this too, Dr. Greenberg, is that when you're in TSW, I think you become afraid of everything because you feel like you're reacting to everything. So people start connecting dots where maybe there are some dots to connect and maybe there aren't. It feels like this caused a problem, but in reality, it wasn't really that. It could have been the fact that maybe it was the issues under the surface, like gut dysbiosis or something else that's causing the flare. But because you happened to take something at the same time this happened, you assume that because what you took, that was the problem.
Jennifer:
What are your thoughts on that?
Dr. Greenberg:
One hundred percent. It's hard sometimes to detangle what's causing TSW to flare or what's causing eczema to flare for that matter. If only we had clarity all the time. A lot of times it's like, “I really don't know,” because there's a lot of factors and we don't even know all the factors. Were we exposed to something that we have issues with? But I also think it speaks to the fact that anyone can go buy herbs, anyone can dose themselves and supplement in any level. When you have people out there who are experimenting on themselves with herbs and they have no knowledge, no formal training, no real understanding even of the adrenal system and how that works and how herbs can impact it, yeah, I mean, you could take an herb and cause problems for yourself. There's not doubt for that. But just because somebody who's not educated took an herb that was inappropriate for them, even if let's say it was Ashwagandha, does not mean that Ashwagandha is inappropriate for all people with TSW. You have to know what you're doing.
Dr. Greenberg:
That's why I really recommend that people go to providers who understand TSW and are properly, formally trained in the use of these herbs and supplements, so that you're not getting the wrong thing that could make it worse. I have never found that supporting the adrenals has made it worse, personally in my patients.
Jennifer:
I only think riding it out, while I understand, but then part of me is like, “Really?” Because your body needs support. I almost look at it as a really depleted state where you do need support to help bring the system back up almost in a sense. But again, this has been my experience. What about too, I also find that people tend to be very depleted in certain nutrients across the board. It just seems at times almost difficult to get their nutrition levels to come back up. Maybe it would take someone a month or two to get a low vitamin D or something to come back up to a healthier level. But sometimes it's challenging for folks with TSW. Do you ever find that to be the case with nutrient depletions or anything like that that you see in your cases?
Dr. Greenberg:
Yeah and I think it goes back to the gut issues and that original problem with eczema. By the time you get to TSW and your eczema's this bad and now the TSW's that bad, I mean, we like to think we are what we eat. But we actually are what we digest. When your gut is so dysfunctional and messed up, you're not going to be absorbing food and nutrients, you're not going to be breaking down food into those constitute parts. That's why people start to flare with eating foods, because they have a leaky gut, they're not fully digesting their foods. Those large food particles can get into the bloodstream and the body does not know what beef is, it doesn't know what a banana is. It only knows for proteins, amino acids or the very smallest building blocks of food. That's what we break it down and then absorb it through our gut.
Dr. Greenberg:
So if we're not properly digesting and breaking down our food and if we have problems with what we call the brush border in our small intestine, we're not absorbing things. So they really are at risk and that just speaks more to you have to go back to a couple levels. Why did they get the TSW? Because of eczema. Why did they get the eczema? Because they have real gut dysfunction and you have to go back and fix that. So I am testing and treating the gut at the same time that I am treating the TSW. Those two have to come together.
Dr. Greenberg:
I've also found collagen supplementation works really well in my TSW patients. There was just a great meta analysis and systematic review that came out on collagen supplementation. For your listeners who don't know what that is, it's when researchers go compile a lot of different studies on the topic. They searched for all the studies they could find of people being supplemented with collagen and different kinds of collagen. There's marine collagen, beef collagen, chicken collagen, so it was a mishmash of things. But they basically found across the board, that supplementing people, and this wasn't TSW specific obviously, but supplementing people with collagen works. It took sometimes 60 to 90 days, but wrinkles improved, skin barrier improved, hydration improved, all of these things improved.
Dr. Greenberg:
It's interesting because conventional doctors like dermatologists, were pooh poohing collagen supplementation for a long time. Like, “No, how could that work?” Because you eat the collagen but then your body breaks it down into its tiny pieces. So how is that actually helping? But they found it helps. You give those building blocks and yes, the body breaks it down into its little tiny pieces to digest it, but it's rebuilding it again in the skin. And I have found collagen to be very useful in my TSW patients. We know collagen is a problem with them. That's another thing that I specifically give to those patients.
Jennifer:
Is there any specific I'd say gram type dosage? A lot of the serving sizes are somewhere between 11 to 16 grams, depending on the supplements. Do you feel like that's sufficient? Or sometimes do you even consider going higher, depending on the severity?
Dr. Greenberg:
I usually do one scoop of the thing, which is in the ranges you were saying. The study I just mentioned was basically saying starting at five grams, you will see an impact.
Jennifer:
Wow!
Dr. Greenberg:
I don't feel like I need to overload them with scoops and grams and grams of collagen. We just do one a day and the formula I use has an herb in it that's an anti-inflammatory herb. I do special things. But then it also depends on the patient because that's a beef collagen. I will say, there's no such thing as collagen supplementation if you have vegans or vegetarians. Collagen is going to come from an animal source. There are some patients who are pescatarian and you can get marine or fish based sources. But if you have a vegetarian or vegan, you're not going to be able to supplement them with collagen unless they're willing to do it.
Jennifer:
Yeah, and that seems to be the case. Is having the discussion and helping them to make the best decision for themselves, obviously. You talked about saying, “Okay, we have this adrenal issue, so we have to support the adrenals. But then on the other side of things, we have this gut issue and you have to address that simultaneously.” But I find that how compromised the adrenals are will dictate how much you can push the body to deal with what's happening. One of the things that I have concern, is that some practitioners that are really not well-versed, will put people on very, very heavy duty, over the top gut protocols that they just cannot handle. So I'm curious to get your thoughts. Do you find that you have to adjust the intensity of other protocols, like a gut protocol, when someone is in TSW based on what their body can actually sustain and manage?
Dr. Greenberg:
I would say my topical protocol is definitely changed dramatically for TSW. We can talk about topicals in a minute. For my gut protocols, like I said, I'm not using pharmaceutical antifungals or antibacterials most of the time. Unless sometimes if there's a true staph infection we'll do a little doxycycline. But I do moving protocols and I do supportive protocols. I'm not just going to give them a whole mess of antibacterial and antifungal herbs and be like, “Good luck with the die off.” You have to support them. So part of the testing I do shows me do they have something called secretory IGA that helps the body deal with the die off? If they're low in secretory IGA, I'm going to supplement with it. Sometimes if I feel like they're constitution is not that hardy, I might give them a binder with it to help bind up some of that die off. Definitely we're paying attention to how are things going, even with eczema sometimes. If we move too fast, we can cause flares and so we're going to dial it back.
Dr. Greenberg:
But I don't use even super crazy, aggressive protocols in eczema. I have moving protocols and we're dealing with one or two problems at a time. So I pretty much use that still on TSW, but building in that support with binders or IGG or other things that they need. And of course, monitoring and adjusting as needed for the person. But I'm not a like, “Let's address all of your problems at one time anyway.”
Jennifer:
You're not going to do H. pylori, fungal, parasites, all at the same time, all on top of… No.
Dr. Greenberg:
Exactly, exactly.
Jennifer:
With that said, you mentioned topicals and there's a lot of pros and cons. Some people feel like they do need to keep their skin really moisturized, other people are moving in the direction of doing a little bit of no moisture therapy, which I discussed in a previous episode. What are your thoughts on that?
Dr. Greenberg:
Yeah, it is interesting because I feel like we have both ends of the spectrum with TSW. There's people who can only survive by sitting in the bath all day and that's really the only time they get any respite from the torture of TSW. Then other people who go the NMT route and that's a completely opposite route of you're not just putting stuff on your skin, you're decreasing the amount of moisture that you take in. I definitely don't start off with NMT, it's a pretty aggressive protocol and it is pretty tough for most people. You have to dedicate I think at least a month to it and see how it goes. And there are risks involved with NMT. For me, the biggest risk is infection because the skin gets so dry and flaky that it often splits and cracks and bleeds. Any time you get that kind of a compromise in the skin barrier, normally if someone has open skin, we're putting antibacterial things like colloidal silver or salves with essential oil to make sure they're not getting infected. But we can't do that because it's a no topical protocol, so you're hoping for the best.
Dr. Greenberg:
The biggest risk for me with NMT is skin infections and if that happens, you are going to have to address it. You cannot just try to ride out a skin infection. That is going to end very poorly for you, your skin, everybody. Honestly, TSW is tricky to treat because normally when we're just dealing with eczema, when we have redness or if we have oozing and bleeding, we can automatically say, “Yeah, okay this is staph,” and we've even gone beyond staph colonization and we might have staph infection and we have to treat it either topically and/or orally. But when someone's in TSW, their skin lesions and the oozing can look like staph and we're not sure if it's staph. Even what we call excoriations, so the scabs, it can really mimic staph and that is part of the difficulty of TSW. Is trying to figure out okay, is what we're looking at just the TSW? Are you just oozing because it's just that moisture coming out of your skin? Is it just cracked and red and scratches and all of these scabs all over you just the TSW? Or is there a staph problem.
Dr. Greenberg:
So we have to experiment and we try to use the antibacterials and see if it's not making a difference, then it's just the TSW. But if you're doing no moisture therapy, you don't know. You don't know if you have an infection or not. I tend not to do NMT in patients when they're in the red, inflamed skin. With TSW, there's a course. The worst part is the other name, which is red skin syndrome and the skin is red, it is inflamed, it's often oozing. It can happen in certain parts or all over the body and that's where we see the classic sleeves. Where you will see cutting off at the wrists. It's just this sharp demarcation of red, inflamed skin and it stops. That's the worst phase of TSW. Then as things start to get better, you get into this very dry, flaky bit. That's actually an improvement and a calming down and a healing.
Dr. Greenberg:
Then once you go through that very dry and sloughing and you might get the elephant skin. I mean, I have a patient who is a lean, healthy 40-something individual, but there are these bags of skin around his knees. That's the elephant skin right now. But that's actually an improved state. Then eventually the body works itself out and you get through that and you have the normal skin. I don't like to do NMT in the red, inflamed because that's where we have the biggest risk for infection. But I find I don't usually need to go there, that we can usually get things under control by doing proper protocols.
Dr. Greenberg:
I know you and I have talked about how you'll hear these stories that people have been in TSW for six years. I mean, to me, that's crazy. It doesn't have to last that long. TSW is one of those annoying diseases that you can get it completely under control, you're like, “We've done it, the skin is healed,” and for whatever reason, we don't know why, you're going to get a flare maybe in three or six months. Maybe it's not over, over for a long period of time, but you're not really suffering in between those periods. But someone who's just in full blown topical steroid withdrawal for years and years, I think that's just a lack of proper care. If you support the body and get to some of these underlying root causes it doesn't need to go on like that and it shouldn't go on like that. No one should be suffering. To me, that's the equivalent of saying someone with eczema, “Just ride it out. Just give the eczema six years and it'll sort itself out.” Well, maybe, maybe not. Why would you want to spend six years suffering like that?
Jennifer:
Yeah, I agree with you. It shouldn't be that long. Yes, you may have lingering issues. You're like, “Yeah, I have some dry, flaking skin. But I'm sleeping through the night, I'm feeling better, I'm able to get outside. I'm able to do some movement.” You feel more like a normal person and that is, believe it or not, it can be possible within a number of months. It doesn't have to be years. But unless we broaden this understanding, and that's been one of my big concerns here, unless we broaden beyond just TSW alone and if you don't look beyond that, or maybe even say look back as to what happened before this, and start considering both in tandem, you're basically dealing with two separate problems. One of which continues because it's being ignored for something else that started more recently, unfortunately.
Jennifer:
For anybody listening to this, obviously, the goal here is we want to encourage you to look deeper. We're not trying to make anybody feel bad who might feel like they've been muscling along through this and trying to deal with it naturally. Letting their body rebound back to a healthier state on its own. It's not a diagnosis, but what this is, is evolving. There is evolving knowledge about it. Unfortunately for everyone who's in it now, you are literally living through the very early stages of everyone understanding how to address this and that stinks. We all recognize it. There's no real template right now, so we're working together. I feel like all the practitioners who do work with this are trying to work together to help create better tools so that everyone can get better care and get through this faster. That's ultimately the goal.
Jennifer:
Dr. Greenberg, before we sign off, aside from people maybe reconsidering their thoughts around using adaptogens, any other little pearls of things that might be helpful or things that you would recommend? I know Dr. Leo had recommended to me hemp oil supplementally. Anything that you find might be helpful for someone to give a shot or consider?
Dr. Greenberg:
I think when it comes to using topicals, you constantly have to revaluate the TSW because it is very fickle. One week patients can be using this topical and it's working great and then all of a sudden, no they can't tolerate let's say, aloe vera gel, which can be super helpful. They're using it, it's great, and then all of a sudden, nope, can't do the aloe anymore. Or vice versa, they were using this type of oil or lotion and it wasn't working at all. But we come back to it a month later and now that's the thing that gives them relief. You just have to keep experimenting with different topicals and just listen to your body. If it's not working for you right now, set it aside, don't force yourself and find things that are helping.
Dr. Greenberg:
In general, I don't like lotions. I get on my little soapbox and do a talk. Lotions are an emulsion of oil and water and I ask my patients, “What happens when you did your fifth grade science experiment and you poured them together? What happens when you put oil and water together?” Everyone knows they float, they don't mix. So in order to get a lotion, you have to use an emulsifier to smash the molecules together, the water and the oil, and keep them together. Now that you have water, you need to have preservative. A lot of the oil that's used in lotions is actually petroleum based, so you will see things like petroleum oil, mineral oil, petrolatum, that's all byproducts from the gasoline industry. So in general, I like to use oils and not lotions.
Dr. Greenberg:
TSW, I will say is the one exception. The skin is so sensitive sometimes that it can't handle oils. That would be too much for it, so you do want to try to find more natural type of lotions that don't contain as many preservatives, that don't contain petroleum oil. But yeah, I think just keeping experimenting with the topicals until you find something that provides some relief for you for the time being. Then if that stops working, you just keep looking for other things. Really working with a provider who has experience with TSW to help you get through it faster. I mean, on some level the body always works at the pace it's going to work at. But we can definitely do things to support it. And by no means is TSW a quick fix situation, but it definitely can be helped with a knowledgeable provider.
Jennifer:
Yeah, and that is an important point I want to echo. I know it can be tempting like, “Oh, well, I want to deal with this myself. So I'm just going to get a nutritionist, I really love this person or a doctor. I see them writing on Instagram.” If they don't know what TSW is, that's where you can land yourself in big, big trouble. That's what I have seen be one of the biggest problems. Is where someone has worked with somebody who has no idea and they're like, “Well, I'll ask my friends or my colleagues what to do.” Unfortunately, that is a hard pass because I've seen some real disasters of folks who have been put through protocols that were really inappropriate for the combo of what they were dealing with. Whether it was eczema or psoriasis or whatever and then TSW on top. You got to find somebody and work with someone that really does understand what TSW is.
Jennifer:
Thank you so much, Dr. Greenberg. I really appreciate your time and as always, your wisdom. It's so appreciative and I know that everyone listening, whether they're a practitioner or they're a patient going through this, I love that you're challenging. You're like, “No, no, no. We need to reconsider adaptogens. They serve a purpose. They can be helpful.” I really appreciate you sharing all this wisdom because what you're seeing is what is happening in clinical practice. It's not necessarily written about in papers just yet. It's literally on the cutting edge and it's so important for people to hear about this.
Dr. Greenberg:
Well, thanks so much for having me on. As you said, it's still in early days, it's not even considered a legitimate diagnosis now. I know that's going to change in the future. It's people like you talking about it and bringing to light our patients' real struggles with this that leads to a dermatologist talking about it at a conference. And eventually, it will become an accepted diagnosis code. Hopefully we'll get more research then and more understanding to this really terrible disease.
Jennifer:
Absolutely. For anybody who's looking to connect with you, how can they reach you?
Dr. Greenberg:
I'm a licensed naturopathic doctor in California, Oregon and Washington. If anyone is located in those states, I can treat you as a patient. If not, unfortunately, I can't. But you can still check out my website, which is integrativedermatologycenter.com and I can try to maybe get you to somebody who can. There's lots of information on there about eczema and other things as well. I have lots of other podcasts and courses that I teach, so if you go to the about us page and you're looking for more information, that might help.
Jennifer:
Awesome, thank you so much for joining us again on the show. We'll have all of your links in the show notes, but thank you so much for your time. I appreciate it.
Dr. Greenberg:
Thanks, Jen.
