Rebooting the Biome with authors, Dr. Doris Day M.D. and Thomas M. Hitchcock, Ph.D

[Intro] Hey, everyone. Welcome to Facially Conscious. I'm Trina Renea, a medically-trained Master Esthetician here in Los Angeles, and I'm sitting with my rockstar co-host, Dr. Vicki Rapaport, a board-certified dermatologist with practices in Beverly Hills and Culver City, Rebecca Gadberry, our resident skincare scientist and regulatory and marketing expert, and Julie Falls, our educated consumer who is here to represent you. 

We are here to help you navigate the sometimes confusing and competitive world of skincare. Our mission is to provide you with insider knowledge on everything from product ingredients to medical procedures, lasers, fillers, and ever-changing trends.

With our expert interviews with chemists, doctors, laser reps and estheticians, you'll be equipped to make informative decisions before investing in potentially expensive treatments. 

It's the Wild West out there, so let's make it easier for you one episode at a time. 

Are you ready to discover the latest and greatest skincare secrets? Tune in and let us be your go-to girls for all things facially conscious. Let's dive in. 

01:33 Dr. Vicki Rapaport: Good morning to all this morning on the partial eclipse on a beautiful October fall AM. How are you all doing?

01:43 Trina Renea: Good. Good morning.

01:43 Julie Falls: Good. Good morning.

01:44 Rebecca Gadberry: Good morning. And if you're listening to this in December, which I think is when we're airing, it's a beautiful day in October but we're getting ready for the fall and winter.

01:55 Dr. Vicki Rapaport: And today, we get to discuss an interesting topic that anyone with skin should be interested in, and that is the skin microbiome.

We are going to be discussing it with two experts in the field Dr. Doris Day and Dr. Thomas Hitchcock who co-wrote a brand new book that inspired this podcast. That book is called Rebooting the Biome: How Properly Caring for Your Skin Biome Can Do More for Your Health and Beauty Than Any Skincare Ingredient on The Market.

I'd like to properly introduce our amazing guests before jumping into this delicious topic. Bear with me all. This is quite interesting but it's a lot, because these two guests are quite impressive.

First and foremost is Dr. Doris Day who is my New York soul sister and a New York board-certified dermatologist. She is Clinical Associate Professor of Dermatology at NYU Langone and has won awards for her work in research in lasers, teaching and for promoting the field of dermatology.

To me, she's a true derm boss who regularly lectures at national and international medical and esthetic conferences and teaches other physicians in the art and techniques of soft tissue fillers, laser treatments and rejuvenation.

She's a member of countless national and international organizations, including the American Society for Dermatologic Surgery, where she's actually on the board of directors. So cool. The American Academy of Dermatology, Women's Dermatologic Society, New York State derm society and the New York Facial Plastic Surgery Society.

Dr. Day is the author of three additional books: Beyond Beautiful, Forget the Facelift and 100 Questions & Answers About Acne. And you can see her friendly and informative IG posts at @drdorisday on Instagram. 

If you're lucky enough to live in NYC, you could actually be her patient and get the best esthetic derm care available. Welcome, Doris.

04:00 Dr. Doris Day: Thank you. That's a beautiful introduction. Thank you.

04:03 Dr. Vicki Rapaport: It's all true, and there's so much more but we just don't have that much time.

And no less impressive is our second guest, Dr. Thomas Hitchcock, who is a geneticist by education and a self-proclaimed holobiontologist specializing in the skin biome. He received his doctorate in Genetics from Clemson University with a post-doctoral training at the school that I'm not allowed to say in my household because my husband is a Tar Heel. It's spelled D-U-K-E. He also had training at Yale and Weil Cornell University.

He is so cool. He's an inventor and entrepreneur and was the founder and CEO of Xycrobe Therapeutics. He lectures on holobiontology and skin science globally and he has graced us with his time today on our podcast. Welcome, Dr. Hitchcock.

04:56 Dr. Thomas Hitchcock: Thank you for having me.

04:58 Rebecca Gadberry: Welcome, Dr. Hitchcock. 

04:59 Dr. Vicki Rapaport: It's such a treat.

05:00 Trina Renea: Welcome. 

05:02 Dr. Vicki Rapaport: We're going to launch into the microbiome, but first I absolutely want to know how you two met.

05:07 Dr. Thomas Hitchcock: Sure. It was quite a while ago and it seems like every year when we think about back then, it's like a different lifetime. I think I was living in New York City at the time and I was working for a company called Ulthera. We later sold that company to Merz. 

But I called on a notable dermatologist in New York City to see if she'd be interested in doing some work with us and that's how I met Doris. Actually, were going to do a small clinical study in her facility and that's kind of how it got started. 

One of the things that I think we clicked on was that we had a lot of similar points of view when it came to esthetic medicine. There's a lot of stuff that's popular that's not necessarily good, and so Doris and I have, over the years— and not just that, also other things personally, politically, spiritually and all that stuff, we've talked about certain things and clicked on those.

I don’t know, Doris, if you have any other anecdotes there but…

06:19 Dr. Doris Day: Oh, yeah. When I first met Thomas, I work with so many different companies. I do a lot of consulting. I was doing a lot of clinical trials at that time. And meeting Thomas, it was really interesting for me because to meet somebody who was that smart and that motivated and who really wanted to make a difference. 

And while he was working with Ultherapy, he had all these other ideas of things he wanted to create and build and things he was working on. So we had these conversations about our ideas of skin and rejuvenation and aging. They were sort of along the line of pushing and thinking outside the box and pushing what we know to the next level and that always got me excited. When you speak with someone who's smart and who's pushing the boundaries, that's super, super exciting. So I always look forward to our conversations. 

And we kind of looked for excuses to find ways to work together and to meet. As he built his company Xycrobe around those microbes that ended up being a product that he ended up building and was sort of the foundation of us writing our book. What we realized is that a lot of the ideas that he came up with, that he started with, he was basically laughed out of the room. He could tell you the story but there were people who really tried to stamp it down or tamp it down and prevent him from doing more of that work.

But in persevering and getting to the other side and proving everybody wrong, that's something that I think really makes him stand out even more to me.

When Thomas calls me and says he has an idea or a project and when he came up with this book, I was like, “Yeah, count me in.” Because in the best possible nicest way, he is a nerd. It's something that I always aspire to be, a nerd, and I try really hard. But to be what I consider a nerd where you're really interested in the truth and in science and in learning and understanding that what we know now is only what we know now and that there's so much more we need to know, that's really powerful.

That's how this whole idea of rebooting the biome came up.

08:24 Trina Renea: I don't know if you guys know, but our co-host here, Rebecca Gadberry, has been on this microbiome for so many years. She's the cosmetic chemistry teacher at UCLA for over 35 years and she is in cosmetic chemistry. When did you start to learn…

08:43 Rebecca Gadberry: Around 2009, I think it was. I was the first one to bring it into the cosmetic industry, giving talks to cosmetic chemists. I found it interesting on your very first podcast that you did on The Skin Science Podcast back in January of last year between the two of you. I know that's your podcast, isn't it Dr. H?

09:08 Dr. Thomas Hitchcock: Yeah, it is.

09:09 Rebecca Gadberry: Okay. I found it fascinating because you were talking about formulations and how there was a lot of misinformation. I think people are much more knowledgeable now in cosmetic chemistry. I'm a cosmetic chemist. We're actually going to be having a whole segment on cosmetic chemistry products ingredients, pro-, pre- and post-biotics, all of that. 

I thought what you had to say on that podcast was fascinating. I would recommend it to anybody who's listening. Go and listen to that podcast. It's The Skin Science Podcast, and I think it was January 22nd 2022, from what I remember.

09:57 Dr. Thomas Hitchcock: Well, you have better memory than I do because I couldn't tell you when that was.

10:00 Rebecca Gadberry: I just listened to it.

10:05 Dr. Thomas Hitchcock: But, Doris, I call her a friend of the podcast because she comes on all the time and is willing to give her time to talk about some of these important nuances about skin health and esthetics. While I agree that was a great conversation, It's hard to have a discussion about the skin biome in a very concise manner because it's not a simple thing. It's one of those things where I constantly have push back from my commercial colleagues about too much science.

For me, I think that that's what we need more of in esthetic medicine is that there's too much hype.

10:50 Dr. Doris Day: Yeah, there's too much sizzle and not enough steak.

10:54 Rebecca Gadberry: Absolutely. We need more proof.

10:57 Trina Renea: So we have a lot of listeners that are estheticians and doctors but we also have the general public, a lot of them, that listen to this podcast. Can you explain what the microbiome is?

11:10 Dr. Thomas Hitchcock: Yes, sure.

11:13 Dr. Doris Day: 101.

11:14 Rebecca Gadberry: Let's go back to basics.

11:17 Dr. Thomas Hitchcock: The first thing I would say is if you're really interested in getting a detailed discussion about this that you want to take your time listening to for anybody who's listening to the podcast, you can look up Beauty and the Bacteria, which is a series that I put together with my team a few years ago now it seems. I think it is a few years ago now.

It's a 10-episode series and we get into the very nitty-gritty of Microbiology 101, Gram staining and taxonomy and all that stuff. But then we also have highlights. So if you watch episodes one, you kind of get the highlight in nine and ten a little bit more, and then if you watch the whole series you basically can get your Master's degree.

12:02 Rebecca Gadberry: It's excellent. It really is. It's fascinating.

12:06 Dr. Thomas Hitchcock: So the microbiome, one of the things— I don't know if I'm allowed to do this but I'm going to hold up our book.

12:11 Rebecca Gadberry: Yes, please. Absolutely.

12:15 Dr. Thomas Hitchcock: One of the reasons that we chose the words ‘Rebooting the Biome’ for the title is because one of the misconceptions that the microbiome is extricable or it's different from the skin, it's all the same biome.

So when I talk about, when I lecture about this, I don't specifically say that we have to only care for the microbiome. I say we have to care for the whole ecosystem. And so the microbiome is simply the part of our skin biome or our skin ecosystem that is made up of all these different microbes. There's an array of different microbes that can live on the skin. Most of them are bacteria but there's also a lot of fungus. 

And then there's a huge amount of virus that we call phage that are specific to bacteria. They don't infect human cells. They infect bacterial cells. But then there are, of course, other viruses that propagate on the skin as well that do infect human cells, but those, hopefully, are in the minority for most people.

13:24 Dr. Doris Day: His dog is in the book, so my dog is here. If you want to see, Thomas's dog, he may show up but…

13:31 Trina Renea: God, look at that.

13:31 Dr. Doris Day: My dog didn't make it into the book.

13:33 Rebecca Gadberry: You share biomes. 

13:36 Dr. Thomas Hitchcock: 100%. Actually, we say that jokingly but that's actually something that we discuss in the book, is that people in rural areas that have more contact with pets and such, their children tend to have less inflammatory diseases, like asthma and atopic dermatitis and such. People in general in rural areas tend to have less inflammatory skin issues as well.

So people a lot of times over-sanitize when they touch their dogs and everything. And I'm not saying you should go lick their paws or anything, but the fact is you shouldn't be afraid of them licking your face. As long as you take care of them and you know relatively where they've been, it's healthy, actually, to cuddle with your dog and share their biomes.

14:23 Rebecca Gadberry: I have a question.

14:23 Dr. Doris Day: And one of the things about the book that we talk about is we give you the background and the science of the skin biome and sort of help you understand and not be so afraid of the microbes that live in your skin, but if you're an esthetician, dermatologist, somebody who's treating patients and taking care of their skin, the goal is, or even if you're using skincare products, our goal is also to help guide you as to the products you're using, maybe how to layer them, and pay more attention to the ingredients. 

Because as a practicing dermatologist for over 20 years, I will tell you that doing research for this book, my conversations with Thomas, really diving into the biome beyond just the structure and function of the skin itself, which is really what we learn in residency, but paying attention to the biome of the skin, that's a whole different level.

And it's changed the way I practice. It's changed the way I tell patients to use products or how to layer them or what products to use. That's had a big impact. Even in terms of their diet and their mental stress, like the mental state that they're in. All of these things affect your skin biome and your skin biome can affect those things as well.

So our understanding, it's not just an academic exercise. It actually has real-world impact and real-world information that you can act on to see a difference, both in how you take care of patients. And if you're somebody reading the book, how you take care of your own skin.

15:50 Rebecca Gadberry: In the book, you talk about how it's changed how you approach the skin and how you treat the skin. Can you give us some highlights on that? Because you just made note of that here too.

16:02 Dr. Doris Day: One thing that comes to mind immediately is the way I use antibiotics for things like acne and rosacea. I've dropped about 99% of my antibiotic use for those conditions. And I think super, super carefully about am I going to do more harm or is this antibiotic really necessary or is there another way around it?

One of my philosophies in my practice is, always with my patients, that I don't want you to just look better. I want you to be better. Sometimes, when you use an antibiotic or you wipe out the biome, you may initially look better. But in the end, you're really not better because Thomas says it so well, that you can wipe all that out but when you stop, it comes back because you're not being in any way specific in how you're targeting what's growing in the skin. 

When you look at aged skin versus young skin, eczema skin versus healthy skin, what we see is a change in that biome.

And Thomas makes such a great point, and we make it in the book, that if you did a sampling of the skin biome on somebody, like eczema, we talk about overgrowth of certain microorganisms but we don't talk about what's missing from a normal biome that may be impacting and causing that eczema flare. 

So we're always looking for what's wrong, but we're not looking at what's right and how we rebalance what's right in the biome sometimes. And so just by rebalancing the biome, oftentimes your skin condition will calm itself. You don't actually have to put all these external interventions. 

I kind of think of this as like with my kids when they were growing up. They would come to me with an argument and they would both want my attention over that answer, but they were really fighting for my attention as a mom. 

But if I said, “Go figure it out on your own,” and I didn't interfere, they would figure it out on their own and they would get better. 

So if I could create a balanced environment, everything for me comes back to family, but if I can create a balanced environment, your skin will not only figure it out but will also stay in remission from those conditions for longer.

18:04 Julie Falls: I have a question. I'm not a professional. I'm the only host here who is representing the consumers. Dr. Day, I've been listening to you on Doctor Radio forever. I called you before. 

Recently, in the last few years, I was diagnosed with SIBO and found a phenomenal Chinese doctor who really helped me eliminating all kinds of things from my diet. It's been great for my skin as a nice little aside.

I recently had COVID and I had a rosacea outbreak that I haven't seen ever. I'm texting Dr. Vicki and Trina, they're so tired of me, and my photographs. But is this something that can affect the microbiome, like getting a virus like COVID? Would it affect the skin like that?

18:56 Dr. Doris Day: Absolutely. Anything that affects your immune system can cause whatever you're prone to to flare. The trick around that is, one, to do as much supportive care as possible around that illness so that you can minimize the impact it has on your immune system. Then on the other side, to rebalance again. So you may have to go through that cycle of treatments over again.

There isn't a cure for a lot of the stuff we have. Your body can keep getting being pushed into these conditions where your immune system is thrown off balance and those opportunistic bacteria, fungi or viruses can take hold and have an impact. And it can take four to six to eight weeks or longer for your immune system to rebalance itself.

It's not just like my COVID is over, it should get better now. One is we still have to treat the condition and, two, is you have to rebalance your immune system and that can take work. On the front side of it, it's trying to be as healthy as possible over the long course, especially when you go into a change of season or a stressful time, like a COVID wave.

And then on the other side, it's recognizing as much as possible what's off balance and trying to rebalance it and treat the condition at the same time. And then you go back to your baseline.

But I'm sorry that's happening to you. I hope you feel better.

20:18 Julie Falls: Thank you.

20:20 Rebecca Gadberry: Well, Julie brings up an interesting question because, in the book, you talk about the gut-brain-skin axis or the GBS. How do they interrelate and what do we see evidence of on the skin because of that?

20:39 Dr. Thomas Hitchcock: So, really, the gut, the brain and the skin are all intertwined by what Doris just mentioned, which is the immune system. The immune system, in the book we make analogies, and some of the analogies are difficult to kind of stick to for the whole discussion but I try to use like the house, your house, and that the inside is not necessarily the inside of the house where you reside. It's actually technically, if you think physiologically, on the outside. The inside would be like the studs and the electrical— all that stuff is actually inside the structure. It's enclosed within the structure. 

So when we talk about the skin, the skin is actually our largest immune organ, because the immune cells may not originate from the skin but that's where most of them reside because it's the largest organ. Every follicle is surrounded by immune cells.

And so when we disrupt or have dysbiosis, that can affect how the immune cells read the state of the entire body and it can be communicated through cell signaling to the gut as well and vice-versa. Then those things can actually affect the brain.

In reality, it's not like you get a staph infection on your skin and then, all of a sudden, you have dementia. It's not that type of an association. it's more of, and there is some tie-in to diet and such and things like dementia, but that has to do with more so the balance in the skin's biome as a whole. 

As I call myself a holobiontologist, even with people that are trying to look better with their skin and do better with their skin, what most people don't understand is that you can't just take care of your skin. You have to take care of your diet. You have to make sure you're getting enough sleep. It's all intertwined in the same way that the biomes are between the gut, the brain and the skin.

22:40 Dr. Doris Day: The reality is, your skin is really a reflection of those other biomes, in many ways. So when somebody has beautiful, healthy, resilient skin, it's often a sign that, one, their body is healthier and, two, their biomes are in balance. I think that's a good clue.

That's one of the things I love about the skin is that I think it's such a powerful reflection of your overall health and well-being. The more we understand that what we put in our body is medicine and that food is medicine, sleep is medicine, all of these things have a very powerful impact. Many of them are free. But we're sort of looking at that 1% of things we can do in terms of treatments and products and all sorts of things, but the things that we have control over, we're not optimizing and maximizing. 

Really, only about 10% to 20% of how you age is in your genes. How we take care of our genes is over 80% of how we age. In this day and age, with the knowledge that we have about mind-body connection, the biome, things that we can do to keep ourselves healthy, this is really very accessible on many levels, until you get that last 5% or 10% where you you're going for that nth degree, like a Brian Johnson kind of level. I don't know if you follow him but he's a guy who is spending millions of dollars studying how not to age or how not to die, like the way out there extreme and it's interesting to follow. But for the rest of us, it's really not where we need to be.

24:09 Trina Renea: I have a question for you, Dr. Day. You said that you're trying to stay away from antibiotics and that there's an imbalance in the microbiome. How do you look at that? How do you know what's off balance? What bugs aren't there? How do you do that?

24:33 Dr. Doris Day: Some of it we know from studies that were done. We know in eczema, there's certain strains of Staph aureus that may be overgrowing. We know in rosacea there might be Demodex overgrowth or imbalance. 

One of the things that Thomas has really brought to light is that it may not be just the bacteria, like in acne or rosacea or eczema. It might be the strain of the bacteria. That we're learning that it's not just one type of acne bacteria, one type of Staph aureus is causing a problem. That's one of the things of the biome is that when you have the right strain, it can keep the wrong ones in balance and it could keep other bacteria in better balance.

Think of these as communities and think of the communities as having their own set of rules and laws. When you have a balance in those communities of law and order, then the communities are happy and they're living symbiotically. But if you have an outlier that comes in that isn't following the rules, they can throw everybody out of balance and really create havoc.

Sometimes you may have a rainstorm or a famine or something else that happens, which you can think of as your body going through a major physiologic stress or eating too much sugar and having inflammation in the body. That can also affect the balance of the biome.

If you want to think of it in a simplistic way, you can sort of think of it as community and having weather and different influences on it.

The way that I balance that out is I say, “Okay, well, I understand these conditions because I've studied them.” And there is data on things like eczema and doing skin cultures that show certain bacteria overgrowing, so I use that as my base.

And then I say, “Okay, well how am I going to balance this?”

Sometimes it's by looking at the triggers for that. What is that person going through? And it doesn't take very long but it is a very concentrated series of questions that I ask to try to understand, for that individual, why they're seeing what they're seeing and why they're going through what they're going through. 

And then we rebalance all those levels and we make recommendations. Sometimes it's adding supplements, like niacinamide or it's checking their Vitamin D levels or other things are going through. There's a lot of different elements to it and it's different for every person.

For me acne and rosacea and eczema, all of these things are very personalized. Even though there's commonalities to those conditions, the way you approach it with each individual patient is absolutely unique and important. Because if you're going to give them the best chance of having good results and lasting results, you have to understand them.

27:16 Dr. Vicki Rapaport: Also, your comment about prescribing 99% less antibiotics, Doris, I feel like I've sort of been forced to do that by the patient’s request, because I'm sure you've noticed over the years, they're paranoid about antibiotics. And we are the worst, we are the number one prescribers. Dermatologists are the number one prescribers of antibiotics.

27:37 Julie Falls: Not me. 

27:38 Dr. Vicki Rapaport: Not you. You're not in there. But I think that also based on what the patients desire, they want Eastern medicine. They want alternative medicine. It has forced us to really look in that direction.

I totally appreciate this book in at around this time because I'm struggling with, any time I mention the word ‘antibiotic’ to a patient, they jump out of their seat, like, “Why would I ever do that?” So I had to learn why would they…

28:02 Dr. Doris Day: That’s also very California.

28:05 Dr. Vicki Rapaport: Very California, yes. But the timing of this book is beautiful because there are so many people who want to fix things holistically. I really enjoy learning about it so I can have a normal conversation with them rather than always being on the offensive and trying to explain to them why they need this antibiotic. I really, really love the book in that way.

28:25 Dr. Thomas Hitchcock: Right. I'd like to add to what Doris said on the antibiotic story there, is that a lot of people don't realize that the microbes that live in and on the skin actually produce antibiotics. They produce their own versions of antibiotics. So therefore, that's one of the reasons why we titled the subtitle of our book about better than any skincare ingredient on the market, because, the fact is, when you let your body and your biome and the symbiosis between the two work together, they actually do things that we attempt to do in medicine but we just— when we don't know what we don't know, sometimes we end up doing things the wrong way.

An example is we wrote a whole chapter, it's the third chapter in the book, about the species C. acnes, which many people might know as P. acnes. It's the same thing. It's just renamed. The reason why that was important to us was that we needed people to see that there are times in human history where scientists and physicians get it wrong. And then we have to go back when we learn new information and do better. But it's not that we did it wrong, because we didn't know what we didn't know. You can only do with the tools and information that you have. 

In today's world, what we now know is that, as Doris was alluding to, there are microbes that are missing in certain disease states, and those microbes are actually what help to keep the balance. So if you have an overgrowth of Staph aureus, what we do know for eczema, it's not just Staph aureus. It's also Staph epidermidis, which is thought to be a skin commensal.

Recent publications, if you go into my office, I have a whole wall where I've drawn out this huge map of all this— it's very complicated but, in a nutshell, Staph epidermidis secretes a protease that actually acts to reduce the adhesion of the stratum corneum and actually reduces the barrier.

Also, when you have higher pH, which is what Staph aureus creates and likes to grow in, it actually increases the activity of this protease. Interestingly, in atopic dermatitis where you have this happening, you have a lack of C. acnes. It's absent in these lesions.

So this species that people used to vilify actually becomes very important to the health and balance of the skin, because all these things work together. It's not just bacteria. It's also the fungus and such.

And so when we overuse antibiotics, they don't necessarily affect the fungus. The fungus can therefore overpopulate because we've now reduced the amount of the things that balance it out. 

31:09 Julie Falls: Amazing.

31:11 Dr. Thomas Hitchcock: And so there's molecules that each of them are spitting out that keep the other one in check, these antimicrobial peptides that they secrete. And when people realize, we're asked then, “Where do we get antibiotics to begin with,” the answer is we got it from microbes. Microbes is where we discovered antibiotics in the in the first place. So they already have a method by which they keep everything in check.

31:33 Trina Renea: What about the topicals, the benzoyl peroxides and Retin-As and things like that that are killing, obviously, some of these P. bacterias and stuff like that? Is that messing up the whole system too?

31:49 Dr. Thomas Hitchcock: I would say I'm not a huge fan of chronic use of antiseptic anything, really. I think that when we do that, we may see a benefit because you are lowering the bioburden on the skin, therefore your immune system has less to react to. 

But the problem is, and we talk about this in the book as well, I think Chapter 4, in history, people have tried to sanitize the world and humanity and such. What we have found is that animals that we do make germ-free, they're weaker. They don't live as long. They have neurological issues. They have digestive issues.

So the real question, because there are things that we do or that we can't do that our microbes can do. For instance, that microbe that I was talking about, the species C. acnes, it secretes a huge amount of antioxidants. We didn't realize that until relatively recently, about five or six years ago. But there was a huge amount of antioxidants these are putting out, so when we reduce that, we're actually reducing our body's protection. We're actually more susceptible to UV rays and such at that point.

It's not just that. There's other implications as well. But with BPL, benzoyl peroxide or Retin-A, you really have to ask yourself, “Why am I using this?” Because BPL will reduce the overall— it will never get rid of, it'll never sterilize, but it will reduce it but it will rebound. Many studies have shown, there's some that disagree, but there's many studies that show that it rebounds in the same exact ratios. It's basically a way to get it under control but not to reboot or to rebalance.

That's where other things need to come in, like a change in habit or use a topical that actually has a legitimate skin probiotic, not something that calls itself probiotic but that's legitimately a skin-native probiotic. Those things can actually help to reestablish the balance.

There's many things like HydraFacials that I'm not a huge fan of. But HydraFacials are a great way to reset everything because you're going to suck all this stuff out, but you need to have something to put back on. Otherwise, it's going to rebound and you end up with issues.

I would say like I'm not a huge fan of retinoids in general, and I know that's a very controversial stance, but one of the reasons specifically for isotretinoin or Retin-A, is that it reduces the oil production of the skin. That, therefore, reduces lipophilic microbes on the skin.

But, again, I feel like those are the things, those microbes are what are protecting us, actually. We thought years gone by that they were causing acne but it's not that simple and it has to do with the strains of the microbes, the interaction between the microbes and other things, like either genetically or in our environment, that are contributing that we can get under control without trying to basically drop an A-bomb on our skin biome.

34:52 Dr. Doris Day: I'll build on that from the practicing dermatologist point of view, because everything Thomas says is factual and scientific and data driven. And then in the real world, the way that I see it and the way I practice is when I think about benzoyl peroxide, for example, I had all these patients coming in when Proactiv was really big. And they said they used Proactiv and it worked for a while and then it stopped working.

Well, we know that the microbes don't become resistant to benzoyl peroxide, so it wasn't a resistance issue yet it wasn't working. It may just be that the biome was set differently. And so even using that wasn't helping, not based on actual resistance of the microbes to the benzoyl peroxide but because of a shift in the biome. Now, you have a different balance of those microbes and still causing problems in the skin that are acne-looking, even if it's not the original type of acne that we're used to seeing.

The other thing Thomas touched upon but didn't say outright, which is really super important, is that what do these bacteria eat. They eat the sebum, they eat the oils that come from the oil-producing glands. So when we do things, and that's where he was going to with retinoic acid, isotretinoin and even maybe HydraFacials is that you're reducing those oils and the oil production, which is reducing the food supply for some of these microbes which can also set the balance off.

But it doesn't mean that those ingredients or products or treatments aren't good. It just means we need to learn how to use them. Do we want to cycle them? Do we want to adjust how we apply them? I think that's our next level of learning.

With my patients on retinoids, I often cycle them or I use forms of them that are not retinoic acid, the active form, but pre-levels of it where the body will convert what it needs, and it has different effects in the skin. So for my patients who I'm not directly treating acne, I will look for the non-prescription formulas and look at what else I'm combining in order to optimize that. And then also maybe cycle the retinoids even in my acne patients where, once they're clear and we have the oil production balance, because we don't want it overproducing either because that can overwhelm the bacteria. 

And your skin doesn't always balance itself that well. Sometimes it needs a little bit of help based on your hormonal status and what your body is producing. So we do need these products but we have to use them thoughtfully, not just prescribe them to our patients with 10 refills.

37:21 Rebecca Gadberry: My question is you were bringing up sebum and I know these bacteria secrete lipase in order to dissolve the sebum, but the lipase is also irritating to the skin and can trigger immune responses. Is that true? Because I've been teaching that at UCLA and talking about it, but I wanted to get your take on it.

37:43 Dr. Thomas Hitchcock: Not necessarily. The thing is, again, we as a scientific and medical community had limited knowledge until, like you mentioned, roughly maybe 12 years ago when we started to see this flood information come in because of the advent of better gene sequencing technologies.

One of the things that we have observed is that it's not even just the right microbes. It's the environment in which you put the microbes that can change their activity. It's not as simple to say this microbe is good or this microbe is bad, because a microbe that is commensal or even symbiotic, if it's put in the wrong environment, can actually be pathogenic.

38:25 Rebecca Gadberry: Can we backtrack for just a second? Because I think a lot of our listeners don't know what a commensal bacteria is.

38:32 Dr. Thomas Hitchcock: Okay. A commensal is what we would call something that lives in or on your body but doesn't necessarily do anything. It doesn't add benefit. It doesn't add any pathogenicity. It doesn't hurt you. It doesn't help you. It just kind of lives there. It just exists there. They use that term loosely because like I don't call a beneficial bacteria commensal. I call it a symbiote. That's where I'd say there's some differences in the way people use terminology. But, for the most part, commensals are considered benign, if you will. Benign microbes.

I’ve lost my train of thought. Oh, the lipase thing. The fact is one of the things— and so Doris was actually— I think it was one of these first podcast where we had James Leyden as a guest as well as Doris. 

James, who was kind enough to lend us his time, spoke to the fact that he and his group were the first to report that C. acnes, which was called Corynebacterium acnes at the time, before P. acnes, now C. acnes again, but he was the first to report that they actually were in the follicles of pustules of people who had acne. 

But he wrote in that publication that it's not necessarily that they cause acne, it's that that's their home. And when you block the pore, it becomes a much less aerobic environment, which is the perfect environment for them to grow. And so when they're growing and the oil is collecting and such, they're just doing their thing. It's not that they're being pathogenic, it's just they're doing their thing. And when you have an accumulation of certain things like lipase in a microoxic environment and such, that's a very different thing than normative skin where you have some oxygen and it's a more controlled growth.

So the real question is why did that pore get blocked in the first place? It's not that the lipase caused that necessarily. That's where there's that big web that I was talking about of all these things balance each other out. For instance, Malassezia, which is a genus of fungus, there's several different types that are associated with certain disease states. Most people probably know it from dandruff. But Malassezia is on the skin and it actually has an interesting interaction with the skin microbes, one being C. acnes where the presence of Malassezia actually allows C. acnes to grow better, based on some research. But C. acnes actually is mycostatic for Malassezia. So it actually balances out, makes sure the fungus doesn't take over.

But, interestingly, Malassezia actually produces certain things that cause hyperkeratinization. Hyperkeratinization is what happens when you have acne. You actually don't typically have keratin in the inside of the follicle but you end up getting keratin inside the follicle which actually closes it off. 

So the real question is what is the actual culprit? Is it really this lipase or whatever is being secreted by any given strain? Is it any strain in particular to begin with? Or is it something that disrupted the balance? If C. acnes is reduced, which, by the way, there's several studies that have shown that the more C. acnes, the healthier the skin. It's actually people with acne have less C. acnes overall in their skin.

And so the real question is what is causing those issues? A lot of it could be environmental. If you put the wrong topicals on your skin, it will cause the microbes to secrete very different things than in their normal state, especially if it's antagonizing them. It's like an animal caught in a corner. It will fight back.

And so bacteria, when they're not in the place where they're happy, they tend to fight back. A lot of that will be by secreting things like collagenases or hyaluronidases and stuff, and they do that because, if they're not happy where they are, they're trying to find somewhere else to go.

42:51 Dr. Doris Day: Tom, let’s talk a little bit about that fungal acne component, because that's a big thing on the internet right now.

42:57 Dr. Thomas Hitchcock: Yeah. This is a question that I've asked Doris over the years, and other clinicians as well, which is a lot of times I've heard people say like, “Oh, this is acne and this is folliculitis,” that is often misdiagnosed as acne. My question is what is really the difference? Is it the strain that you culture? What is the difference between folliculitis and acne because they present quite similarly. 

There are differences between certain types of pathogenicities when it comes to pustules and such that are thought to be acne, but we all know that rosacea can present with some pustules as well and so different disease states can present.

With the fungal acne, interestingly, there's a publication— and of course, this is anecdotal because it was just reports in the literature. But there were reports of several people that some of them were on hormone replacement therapy, some of them weren't but they were having acne issues. They gave them, for whatever reason, not for the acne, but they gave them an antifungal, an oral antifungal. It cleared their acne. And when they would get off the antifungal, it would come back.

And so the thing is we have to really respect that sometimes it's not just because there's fungus, it's not just because there's C. acnes, it's because the balance may not be. It's not just the strains, it's the balance. It's also the environment. So what are you doing? What are your habits? 

We have a line that’s called BIOJUVE that basically is…

44:28 Julie Falls: I was just going to ask you about that and to explain Xycrobes too.

44:31 Dr. Thomas Hitchcock: Yes, the Xycrobes are in there.

44:32 Julie Falls: Yes, can you tell us about that?

44:34 Dr. Thomas Hitchcock: Sure. It's the world's first skin biome care regimen. We call it skin biome care, not skin care, not because skin care is bad but we feel skin care doesn't go far enough. And so there are skincare elements to it but, basically, it all centers around this technology.

Doris was one of my first cheerleaders…

44:58 Dr. Doris Day: And guinea pigs.

45:00 Dr. Thomas Hitchcock: Yeah, and guinea pigs as well because she would use all the products in their different forms, and she still does.

But about 2013, I started this company Xycrobe Therapeutics and the BIOJUVE comes out of that. So there's a lot of stuff as far as how the technology can help things like psoriasis and eczema and dermatitis and acne and such. 

But the BIOJUVE products was because when we were doing our research for psoriasis, we noticed that the microbe itself, we put a little genetic switch to turn off its ability to divide, but the microbe itself was doing all sorts of stuff that we never knew it could do. Because, remember, this is the species that people were saying is a pathogen. And Doris talked about it, but when I first went to my very first meeting for investors and I pitched the idea, one of them called me delusional because they thought that C. acnes is a pathogen. Why the heck would I use a pathogen as a therapeutic? It made no sense.

I tried to explain to them but I just didn't have enough data at the time. Now, I have notebooks after notebooks full of data. We just published our second paper on the technology, but basically what we were saying was that this specific— and this all came, the inspiration for this came from UCLA. There was Dr. Lee who did a paper in 2012 that showed that in people with acne or normal skin, everybody had about 89% C. acnes. It was just that there were different ribotypes or strains associated with the disease state.

Now, nobody has answered the question why they're associated. A lot of people think, like we just discussed, that it's because they secrete inflammatory molecules. Certain strains do over others. I don't believe it's as simple. I think that part of it is also that they don't have the right antimicrobial peptides and such to keep things out that shouldn't come in, and so it's the balance again.

But we noticed that this particular strain that we had isolated from actually a gentleman that was changing our trash in my lab in San Diego, because we were swabbing everybody trying to just collect as many C. acnes strains as we could. We found that this particular strain lowered inflammation in our cell cultures and skin explants as much as pure Interleukin 10, which is one of the master anti-inflammatory cytokines. 

Then we started to see that it spits out huge amounts of antioxidants, that the propionic acid that it secretes in huge amounts, which by the way you should look for things as much as you can with short-chain fatty acids. Every day, I'm more and more convinced that it's one of the most healthy molecules you can have inside your gut and on your skin. 

But the propionic acid, which is a short-chain fatty acid, actually, our cells have receptors for these short-chain fatty acids, just like they do for retinoic acid and all these things. But remember that, in our normative states, we have millions, if not billions of these C. acnes in, not in every follicle but throughout the follicles of the entire skin. And those things are secreting tons of propionic acid all the time.

So our body is used to having this flood for healthy skin of propionic acid and butyric acid and acetic acid in our guts and on our skin. When we get rid of that, we have to think about what's the repercussions when our body's made to do that, which is different than things like growth factors and retinoids and such which our body typically only makes in small quantities, yet we try to flood the skin with those things.

48:41 Julie Falls: It's like when you go get a vaccination and they're using the virus to, so you're kind of using what we already have, right?

48:50 Trina Renea: So what are these short-chain fatty acids? What is that?

48:53 Julie Falls: Wait. Am I right when I say that? Like when they're using a live virus in a vaccination, is it the same kind of thing? You're saying that you're using the C. acnes that we already have and putting more of it into the topical.

49:07 Dr. Thomas Hitchcock: Kind of, yeah. What I'll say is I have to be very careful because there's certain regulations. The FDA doesn't allow me to make drug claims and such. It doesn't matter what it does. But what I can speak to generically for C. acnes in general is that there have been publications which have shown, and we have shown one in our labs, that certain strains that are associated with health actually cause the immune cells in the skin to switch to a quiescent state, meaning they actually go out and seek out the bad microbes and kill them versus when you have the pathogenic-associated strains. Those ones don't do that.

That's been shown in several studies now and so there is an immunomodulatory function to the right microbes on the skin. It's essential, the balance, because there's all these roles that need to be played and they typically know how to put those intact. 

The skin biome, BIOJUVE as a whole is made to basically do three things. It's to provide the skin with the right microbes, the right environment and then the food source to keep them all happy, the skin as well as the microbes. That's really, it's a very concise line for that reason because all we want to do is keep the microbes happy and safe.

50:27 Julie Falls: Dr. Day, are you still using it?

50:30 Dr. Doris Day: Oh, yeah. Yes. I mean, once you start using it you see. And I think I might have been the first office to carry it. But when patients use it, they will come back and tell me that they see the difference.

I just had somebody yesterday and she was just so thrilled because she hadn't used anything else that had gotten her skin to this better state. And I haven't had anybody react to it. There was one version of it that Thomas got pushed to adding a little bit of retinol into. He really tried to fight against, but retinol is such a popular ingredient.

But, actually, the pure BIOJUVE, and I think that's the only version of it now in terms of the active microbes. What I tell patients is you just need one pump and you mix it on the back of your hand and add the activating spray, which is the prebiotics. It's the food for them. Then you put it on your face once it's all blended. You can use more of the water, but there's a billion of those microbes just in a pump so you don't need to use a lot. 

And that's really super important. Giving people instructions on how to use any product is super important. Also, because they're live microbes, there's no preservatives. I'm very careful as to what else they use before and with it, because preservatives can knock out the microbes. So it's a very specific skincare routine.

Some people are hesitant to give up products that they're using that they like, but once they start making those switches, one, is they save a lot of money because they're not using a lot of other stuff and, two, is they just like their skin better and it makes it super easy.

And then the postbiotics, Thomas will go into a little bit more, but those are the antioxidants, the short-chain fatty acids, propionic acid, all those things that those microbes make that act like Vitamin C and act like retinol and do what you want from those other ingredients, but it's all letting your skin do for itself what it needs.

And your skin ends up more hydrated. So if you have very oily skin, it ends up being less oily, not because you're making less oil but because these microbes eat the oil. You're not really changing the production directly. I'm not using something that's going to reduce the sebum production directly or in a toxic way, like I might with oral isotretinoin or with a laser, which actually worries me even more. 

Although I use a lot of oral isotretinoin in my younger patients when I'm trying to get them into balance, especially if they're scarring. And then once they're done, I'll switch over and I'll try to add in BIOJUVE for maintenance. So it's not eliminating my other treatments. What it's done is it's given me a holistic approach for patients who want it and it's given me an opportunity to have options in how I manage my patients with acne.

But if you want to dive into the free fatty acids and what they are and go into detail on that, that's fine, Thomas. 

53:27 Rebecca Gadberry: We're actually running towards the end of our time together.

53:30 Dr. Doris Day: I'll just take over running the podcast. It's okay.

53:32 Julie Falls: Please. 

53:33 Dr. Vicki Rapaport: Dr. Day, if you can stay longer, we'll keep you.

53:39 Dr. Doris Day: I know, though I have to go. Unfortunately, I have my grandbaby.

53:41 Rebecca Gadberry: Such a cute little guy. This has been probably one of our top five most interesting conversations on this podcast.

53:46 Julie Falls: Amazing. I have 400 more questions.

53:53 Rebecca Gadberry: I know. 

53:54 Trina Renea: Of course we're going to have them back, or Dr. Day back to talk about…

54:00 Rebecca Gadberry: Yes, and I would love to interview Dr. Hitchcock as one of our founders, because he has definitely got one of the most interesting…

54:09 Trina Renea: Don't put him on the spot.

54:11 Rebecca Gadberry: Paradigm-shifting and disruptive concepts in our industry.

54:17 Dr. Doris Day: And he has such a great voice.

54:18 Rebecca Gadberry: Yeah, and he's adorable too.

54:19 Trina Renea: And I want to try the products that he's talking about.

54:23 Dr. Doris Day: I know. It's all true.

54:27 Rebecca Gadberry: You're so young, Dr. Hitchcock. You're so young for everything you've done. I'm marveling at how much you've already contributed and how much more you have to go. It's amazing.

54:41 Dr. Thomas Hitchcock: I appreciate it. It's very kind of you all to say. 

I do want to make sure I point out a quote in our book that I used that Doris would tell me all the time as I was developing this, because I would get nervous that people would have the reaction of, “How dare you say not to use retinoids,” or, “How dare you say not to use antibiotics.” Doris often says to me that I need to be a little more diplomatic in the way that I approach this because I would fight back and say, “Look, you know what? You didn't know this information and now there's information saying that you shouldn't do these things.”

And Doris would say this, basically this is the quote. “Do the best you can until you know better, then when you know better, do better.” That always resonated with me and I was like, “Doris is so wise.” I found out it was actually from Maya Angelou. She never claimed it wasn’t. 

So I kind of split attribute that quote to Doris as well as Maya Angelou. But I wanted to point that out…

55:45 Dr. Doris Day: Maya Angelou can get all the credit, seriously. 

55:49 Trina Renea: As long as you practice what you preach.

55:52 Rebecca Gadberry: She had great skin too.

55:54 Julie Falls: Yes, she did. Well, thank you so much.

55:59 Rebecca Gadberry: It's been amazing.

56:00 Dr. Thomas Hitchcock: My pleasure. 

56:01 Rebecca Gadberry: It's gone by so fast. 

56:04 Dr. Thomas Hitchcock: Yeah. I'm going to hold this up again. Don't forget to pick up one of these.

56:07 Trina Renea: Yeah, Rebooting the Biome.

56:09 Rebecca Gadberry: We also want to say Rebooting the Biome you can pick up anywhere on Amazon. I have it on Kindle. I've been reading it. It is so conversational. It is so explanatory. You are so not only innovative but you put it in a very logical, easy-to-understand way. A lot of these books on the microbiome and skin are very difficult to understand. And everything you say is relevant and mind-blowing. Almost everything is mind-blowing in this book.

You also have your podcast, which is The Skin Science Podcast, and you've got Beauty and the Bacteria video series. We'll also have some entries on our blog of things that you have written, Dr. Hitchcock and Dr. Day, so there's resources that will be at the facially.com.

57:05 Trina Renea: Faciallyconscious.com. Is it on Audible as well?

57:09 Rebecca Gadberry: Yes.

57:12 Trina Renea: Great. Good.

57:13 Rebecca Gadberry: It's amazing.

57:15 Julie Falls: It's so timely, because you go to Instagram and everybody is touting some kind of a product for the gut, for the microbiome, and there's colostrum and then there's collagen. And you have to do this and I've never felt better and don't forget your greens, blah, blah, blah.

So just to have this all brought into something that we can relate to, understand…

57:36 Rebecca Gadberry: And I think people, I have more questions about what you can do to rebalance your biome, but I suggest that you get the book. And maybe we'll bring it up in a future podcast as well.

57:47 Dr. Thomas Hitchcock: Sounds good.

57:48 Trina Renea: Thank you so much.

57:49 Julie Falls: Thank you, guys.

57:49 Dr. Doris Day: Thank you.

57:50 Dr. Thomas Hitchcock: Thank you for having us.

57:52 Dr. Vicki Rapaport: Thank you both. Bye. Have a lovely rest of the day.

57:55 Trina Renea: Bye.

57:55 Rebecca Gadberry: Bye-bye. 

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