Andrew: Cool. Can you take us through the different types of acne and how you assess these in the client? Because some people say, “Oh, you know, the high acne, the low acne, the chin acne.” It’s not quite as defined as that, is it?

Asha: It’s not. It would be a lot easier if it was, but, you know, I’ve seen everything, and there’s no definitive pattern, unfortunately. There are some general patterns, and there definitely is becoming more awareness of inflammation as the biggest driving factor. So we’re steering away from hormones. We’re not saying that hormones don’t play their part, but what we’re saying in adult acne cases, and adult acne being women that are over 25, but only about 3% of them are gonna be solely hormonal acne, so we definitely take that into consideration. So when we’re looking at hormonal acne, that’s quite straightforward because we can pick that up in testing. We can see that, kind of, U shape in the face where it’s appearing along the jaw line, the chin, the lower cheeks, and that’s quite a definitive area.

Typically, the women who see me, that would’ve already been picked up because that’s fairly straightforward. So then we’ve got the other types that we see, which is very much the stress connection, so chronic stress elevating cortisol, which increases that sebum production and inflammation. That can appear more randomly, but you can hear your patients say things like, “I went on holiday and my skin cleared up.” We’ve got post-pill acne, again, a very clearly defined one when women are discontinuing hormonal contraceptives. And a lot of time there’s a lot of fear, and then the stress acne contributes to that. And they all interplay, you know? We can’t say that there’s just one in isolation because, for example, with post-pill acne, we’re going to have the stress component because they’re fearful of coming off the pill and having that post-pill acne. There’s gonna be a gut and liver involvement because of what that medication has done to those organs. And so it’s all interconnected, which is why it makes it quite complex to treat.

But what I do love treating in clinical practice is the gut-related acne, so that connection to gut pathogens, parasites, H. pylori, SIBO, food sensitivities, leaky gut, all this stuff that we’re gonna dive into today. And a lot of our patients, so 90% will do stool testing, even if they’ve got no symptoms, because there’s such a strong connection between the gut and the skin. The other interesting ones that we can see are the connection between mineral disturbances, like copper excess and zinc deficiency, microbiome overgrowth mimicking as acne. And what I mean by that is actual overgrowths in the skin microbiome that mimic acne but they’re not acne. They need to be treated very differently from the outside in. And then, our mold, mycotoxins, heavy metals, and environmental allergens, which, over the course of my career, I’ve seen increase more, and more, and more.

Andrew: So let’s dive into the gut, forgive the pun, and explore those processes at play in the body. You mentioned certain infections. H. pylori was really interesting to me, but could we dive into that a bit and talk about how you assess, and what sort of variations, if you like, in treatment, or how you tweak treatment?

Asha: Yeah, absolutely. When we’re looking at the skin-gut connection, we know that it’s undeniably there. And if someone is having skin issues then it’s very likely that this is stemming from the gut. So when we’re looking at signs that aren’t gut connected, when they’re not presenting with overt gut symptoms of bloating, constipation, diarrhea, those kind of things, we’re starting to look at, is there malabsorption? Do they have low iron, low B12, zinc, and do they say that this has always been the case for them, and no matter what, they can’t bring it up? Do they have unrelenting fatigue that can’t really be explained? Do they have acne that can’t be connected to the menstrual cycle? Is there a big stress component? Have the hormones been tested and they’re within range? And those are the kind of things that I’m looking at, but like I said, we do test about 90% of our patients.

So when we’re looking at the gut-skin connection in acne, what’s really fascinating to me is how interconnected these systems are. So the intestinal microbiota isn’t just sitting there passively. It’s actively involved in acne formation through several key mechanisms. So I like to think about it this way, that both our gut and our skin are incredibly vascularized and innervated tissues, and they’re both performing complex neuroendocrine and immune functions, which means they’re constantly communicating with each other. It’s like they’re having this ongoing conversation through the nervous system, our hormones, and our immune pathways. So where it gets really interesting for practice is that essentially we know that the gut microbiome is our first line of defense, and so is our skin, but it’s determining how our body responds to everything we’re consuming. So when the microbiome is balanced, we get proper immune tolerance, but when it’s disrupted, we start seeing inflammatory cascades related to immunity that can manifest as acne.

We know some of the things that are disrupting this, right? So the Western diet is a major culprit, throwing off that delicate balance between beneficial and pathogenic organisms. But something I find that’s relevant is that stress has a big impact. So stress will have an impact on our friendly bacteria, particularly the lacto and the bifido. It’ll have an impact on our secretory IgA, so our immunity, and it will have an impact on our gut permeability, so creating leaky gut as well. So we know that the gut, and these bacteria, and intestinal health markers are incredibly stress sensitive, and when we’re chronically stressed, these microorganisms can actually switch from being protective and anti-inflammatory to producing inflammatory neurotransmitters. And then the real protective mechanism that I work strongly with is that the healthy microbiota produces short-chain fatty acids, including the propionic acid, which is actually protective against staph aureus and the C. acne’s bacteria in the skin. So the research in this area is still emerging. We’re often working clinically ahead of where the research stands, but it is coming, and there’s more and more exciting research at play. But the short-chain fatty acids directly affect the skin in a few mechanisms, so it’s really important to focus in on those.

Andrew: And so talking about gut inflammatory markers, which markers do you find of most clinical benefit for you? For instance, a Medika might use something like calprotectin when they’re looking for an inflammatory bowel disease. Do we go that, do I use the word, “gross,” or do we have to use the more nuanced inflammatory markers?

Asha: Yeah, it’s a really good question, and I would definitely say that we need to be more nuanced. And in seeing so many reports for acne, and I’m definitely gonna talk about SIBO and H. pylori in a moment. But when we’re looking at…the first thing I look at in a report is the intestinal health markers. And so I’m very much looking at those as the protective mechanisms of the terrain or the environment. And yes, the calprotectin one is a big one, but we know there’s gonna be a huge amount of inflammation generated if zonulin is present, and also, looking at those gluten antibodies, and looking at the secretory IgA. When I look at the secretory IgA, I like to also have a look at Akkermansia phycoli and roseburia, because that’s gonna give me an indication of the health of the mucosal lining. And we know that if the mucosal lining is thin and fragile that there’s going to be inflammation there as well. So having a look at all of those markers in the context of inflammation is really important.

Andrew: It’ll be an interesting day when Akkermansia muciniphila is going to be available for clinicians, isn’t it? It’s available already overseas, I understand.

Asha: Yeah, I do use the overseas one, yeah, as well as polyphenols, and all of those other great things. Yeah.

Andrew: Yes. Now I love what you’re saying there about feeding the bacteria. Because in the olden days, gray hair, it was all about, “The bacteria, the bacteria, the bacteria.” And then, we realized, as soon as you stop, the effects go away. There’s a lot of genetic imprinting. So if you need that beneficial effect to keep going, you had to take more, you know? And then we realized, “Hang on, these things eat,” duh. So it’s just, it’s really an interesting clinical facet to explore with the diet, and how the dietary inclusions of things like polyphenols, fibers, etc., can influence the microbiota. Can you tell us a little bit about that, just your clinical experience there when you’re treating acne?

Asha: Yeah, absolutely, love to. So when we’re treating acne, one of the things that we need to keep in mind is that most of our patients will have been on pretty hectic acne medication, and not just for a little while, like, for a long time. And so that’s the first thing I’m thinking when I start to look at a report. I’m like, “Okay, I know this person has done three rounds of Roaccutane. I know they’ve had multiple antibiotics, and they’ve been on the pill. This is gonna have had decimating effects on the microbiome.” What’s really interesting is the clients that are currently Roaccutane and looking at their reports. Because the literature is a bit wishy-washy, but when you look at an actual report of someone who’s on Roaccutane, it’s quite undeniable the effects that it’s having on those short-chain fatty acids, and the mucosal lining, and the calprotectins. It’s undeniable. It’s undeniable, and it’s often a little bit sensitive to chat to people about that when they’re taking those medications as well.

But generally speaking, I will do a three or four-phase gut protocol. So the first phase is very much about addressing those intestinal health marker vulnerabilities, knowing that we’re gonna have to support those for the long term, but also addressing their commensal bacteria through probiotics, prebiotics, fibers, dietary aspect. One of the common things that I see is the bacterial phyla being disordered. And you’ll say to someone, “Look, how much fiber are you eating?” And they’ll say, “I’m following what you asked me to do. I’m eating half a plate of fruit and vegetables, like a rainbow on my plate at every meal.” It’s linking back to, you know, digestion is a top-down process. And so we’ve gotta remember what’s happening from the top down as well, and how much is the gallbladder, and the bile, and the liver impacting on that commensal friendly bacteria as well. So often I’ll work a lot on the bile because that’s, like, the bile, the hydrochloric acid, pancreatic elastase, they are the guardians of the gut. And if we don’t really honor and acknowledge them, we’re just gonna be throwing probiotics at someone for a long time.

Andrew: I love what you’re saying, “The guardians of the gut.” That’s brilliant. You said you’d like to discuss a little bit more about H. pylori, and SIBO, and its link to acne. Can we delve into that a little bit?

Asha: Yeah, absolutely. So actually, I’m not sure if you’re aware of Dr. Julie Greenberg. She’s a naturopath from the States and I’ve followed her work for a long time, and her work has been a real game changer for me. She did a clinical-based study using stool testing on organic testing from her acne patients and the numbers were staggering. This was what piqued my interest in H. pylori and the acne connection. Because what she found in this clinical study was that 92% of her acne patients tested positive for H. pylori, and that was just so significant to me. So when you start to delve into that deeper, the research is there for that outside of that clinical-based study. So we know that what’s happening with H. pylori is it’s a very clever, sneaky bacteria that produces urease, and that job of the urease is to neutralize stomach acids because it wants to create a nice alkaline buffer around itself to survive the environment. So when we’ve got that effect of the H. pylori suppressing stomach acid, we know there’s a direct connection to acne and hypochlorhydria. That’s known. But we know as well that we get suboptimal digestions, so we’re not breaking down our proteins, but then we’re not breaking down things like zinc and iron that are crucial for skin health.

The stomach acid is a signal to gallbladder and pancreas, which I’m very passionate about. I do a lot of gallbladder and bile work in my practice, and when that signal is compromised, we’re seeing that poor fat digestion and enzyme production. We might see that steatocrit rise, which directly impacts the absorption of fat-soluble vitamins that are so crucial for skin, like your omegas, your vitamins A, D, E, and K, all essential for skin integrity. So if someone is saying, “I can’t get my vitamin D levels up as well,” am I looking at the liver and the gallbladder? Yes, but am I looking at H. pylori as well? Yes. And then the third and the big one is that we’re losing that killing power, so the stomach acid as our first line of defense against pathogens. And when we’re seeing an overgrowth of the opportunistic bacteria, the yeast, the parasites, then that first guardian of the gut is on its extended leave and can’t protect us.

But this is where the research gets really interesting with H. pylori directly connecting to acne. It doesn’t just mess with our digestion. It actually induces nuclear inactivation of something called FOX01 in the gastric cells. So FOX01 is this transcription factor that’s like a master regulator, and when it’s functioning properly in the nucleus it will keep things like IGF-1 and the mTOR pathway in check. Remember that that mTOR pathway is a protein kinase that plays a significant role in acne development. But when H. pylori knocks that FOX01 out of the nucleus, we get this cascade of increased sebum production, cell proliferation, inflammation in the pilosebaceous unit, and basically, that’s causing acne. So I say to my patients that their acne might just be a problem with lack of FOX01 in the nucleus. It’s maybe a bit more of a straightforward way of explaining how a gut infection can show up as acne.

Andrew: You’re giving me so much to think about, Asha, I’ve gotta say. Can I just interject? Talking about long-term usage of vitamin A analogues, like Roaccutane, and we’re talking about the imbalance, if you like, or the contesting of absorption of fat-soluble vitamins, do you find things like…well, you mentioned, “Why can’t I get my vitamin D up?” And then what I’m thinking is, you mentioned the mTOR pathway and the effect that fat-soluble vitamins have on that, like the FOX01. This is blowing my mind. I really need to go and read some more books. Can I just get the practitioner again? What was it, Julie Greenwood?

Asha: Dr. Julie Greenberg.

Andrew: Greenberg, thank you.

Asha: Yes, yes. So we’ve known about mTOR for a long time, but she was the first person that talked about the FOX01 connection, and then that just sent me on an absolute, like, spiral of research, and very grateful for that. Because we can’t deny that the mTOR pathway is one of the most profound root causes of acne, so it’s driving all acne pathophysiology. And we know that it’s got connections to more sinister health presentations as well, so we could look at acne as an early warning sign for those more sinister health presentations, which is why I love treating acne.

Andrew: Yes, that’s where my mind was going, too, Asha. This is just so interesting to me. This is fantastic. Can I ask, you mentioned that only 3% of women, was it, that you see have hormonally related acne? Can we delve into that a little bit, how you tease apart those that have a hormone component versus, like, a major driver of the disorder?

Asha: Yeah. Well, the 3% statistic came from the literature. So that came from the literature with late onset acne, otherwise known as adult acne. And I was, like, “Thank goodness I’m not imagining this. I’m not losing my marbles.” Because hormonal acne has been such a marketable term, and a lot of our patients, they’re frustrated because they’re thinking, “I’ve got hormonal acne but it’s not responding to any hormonal treatments.” And a lot of this is down to the fact that the only medications are hormonally related, apart from Roaccutane. And so it’s been a very easy black-and-white term to use with connection to acne. It’s hormonal. So it’s obviously a lot more complex than that, and it is easy to test for hormones, and I love that. So one of the foundational things that I do is I run serum pathology. I’m looking at a number of things, not just the hormones. And when I talk about hormones, I’m not just talking about sex hormones. I’m talking about insulin. I’m talking about cortisol. It’s very important that we recognize those.

IGF-1 is really important to acknowledge as well. So like I said, if the people who come to see me have tried everything and I’m not their first naturopath, usually that hormonal stuff has been picked up, or a PCOS diagnosis has been picked up before they see me, so my clinical experience might be a little bit skewed because of that. I do want to mention that our skin is an endocrine organ and it has its own hormone receptors, and we can’t test for that. So you could theoretically be testing someone’s serum pathology for antigens and they all come back within the functional medicine reference range. However, in the pilosebaceous units, their hormone receptor may be extra sensitive, and that’s the genetics of it. And it’s actually picking up a lot more DHT than we would actually know from any testing, so there’s that.

But in my practice, I treat the gut before I treat hormones because there is such a relationship between hormonal imbalances and gut health. So we’re finally understanding, as I referenced before, that acne isn’t a hormonal condition. It’s a systemic inflammatory condition where the gut-skin hormone axis plays essential role. So we can understand that when there’s a dysbiotic gut there’s a cascade of systemic inflammation, and we’re having increased intestinal permeability, and leaky gut, and we’ve got LPS and bacterial antitoxins crossing into the circulation. But what we need to understand is that this is not only triggering inflammatory pathways and other cytokines, but it’s directly influencing sebaceous gland activity and keratinocyte proliferation, so it’s intersecting with hormonal pathways.

Andrew: Forgive me.

Asha: And we know that the gut bacteria participate in hormone metabolism so they produce enzymes like beta-glucuronidase that can deconjugate the estrogens. It’s bigger than beta-glucuronidase, but it is important. And the PCOS connection is relevant here because many of our female acne patients will have underlying insulin resistance, and even if they don’t meet the full PCOS criteria, if they’ve got insulin resistance and they’ve got dysbiosis contributing to insulin resistance, that’s going to increase their IGF-1, and stimulate sebaceous glands, and increase free antigens. Yeah, so we know butyrate is gonna help maintain insulin sensitivity, and we know…

Andrew: So…forgive me. Sorry, I cut you off. Sorry.

Asha: No, please.

Andrew: So what I was gonna ask is, so by treating the gut you’re really handling the enterohepatic circulation and letting the hormones having done their job to get out of the body. But there is that component of overproduction of certain hormones, antigens, blah, blah, blah, PCOS, the acne-related stuff there. So do you solely focus on the gut and let the terrain help to manage itself? And do you find that once you get that terrain balanced it can, sort of, self-manage itself backwards, or do you have to, at some stage, use hormonally balancing herbs, and things like that?

Asha: Yeah, it’s a really good question, and the way that I treat is that I don’t look at hormonal panels in isolation. I think that if we don’t address the underlying gut dysfunction, we’re missing a crucial piece of the puzzle. And the research is showing that the gut microbiota plays an increasingly recognized role in hormone metabolism, particular with androgens and estrogens, which for me, makes it the priority for treatment. So I say to my patients, “Give me six months with your gut and then we will re-test your hormones because I only work on one thing at a time, and the gut has to come first, and then we’ll see.” And usually the changes in hormones are quite remarkable by working on the gut, gallbladder, bile, liver.

Andrew: Wowee. Naturopathic axiom, which we tend to forget because we want to change something. We see it as, “That’s out of balance, that’s bad,” rather than, you know, this is what we’re taught in naturopathy. That might be the issue but you have to go back and look at the foundations of health. I love what you’re doing.

Asha: Thank you.

Andrew: I’m so impressed. It’s almost like a rebirth of, like, duh, Andrew, you know? We tend to, sort of, focus on, “The problem that presents, rather than the problem that caused the problem that presents.”

Asha: Absolutely. There has been this westernization of naturopathy where we tend to be looking at it like that. And I think that the more that we can go back to our roots and we can be looking at those fundamental things, including nervous system regulation, they’re better outcomes for the whole of us.

Andrew: Love it. What about external versus internal treatments? People want to feel good. They want to look good. They have to work. I don’t know if anybody can see at the moment, but I’ve got a couple of zits and I’ve had to use concealer because they were pronounced, so gut much? Anyway, so internal versus external treatments, can you take us through a bit please?

Asha: Yeah, absolutely. So I suppose that the skin microbiome is one of my biggest passions. We can’t neglect it and we can’t ignore it. It is the second biggest microbiome of the body, and I think in the next five years the research will explode, and the way that we’re looking at the skin is going to change dramatically. So it’s a hugely missed opportunity not to be supporting it from the outside in, and it doesn’t need to be complicated, and we don’t need to be using very expensive clinical treatments. In fact, I think that that’s a terrible idea if someone’s skin barrier and microbiome are compromised. I, myself, am a corneotherapist and I have been for a very long time. What does that mean? Corneotherapy is similar to corneobiology. I try to explain it to people that it’s a rehabilitative skin treatment tool that shares naturopathy’s principle of do no harm.

So we want to protect the barrier function, repair the skin microbiome, and rather than stripping or disrupting the skin, corneotherapy works with your skin’s natural defense systems to restore balance and function. Because one of the biggest things that I see is that people are using topicals that are doing the opposite of what I just discussed. They’re using products that have got ingredients that are breaking down the skin barrier and the microbiome. And what happens when it’s exactly the same as the gut, when we have a leaky gut? So when you don’t have an intact skin barrier that’s protecting you from the outside environment, and it’s housing your pH, so your acid mantle, and your skin microbiome, so your skin microbiome can’t exist without your barrier, then underlying that is immune cells, and exactly the same as the gut. So if we have a leaky skin, then the immune system is constantly getting provoked, and that’s when we’re seeing redness, inflammation, damage, all of those things that people are desperately wanting to correct. And so if we can just be addressing those defense layers and taking away anything that’s hurting those, we can have dramatic improvement in the skin from the outside in.

Andrew: Very interesting that even the most medically minded, even the most orthodox medicine mind will be recommending an audience for inflamed skin. And that is, indeed, creating an extra barrier so that it doesn’t have to interact with the outside world, if you like. Now not to say that that’s necessarily good, but it’s really interesting, you know, that the inventor of the petroleum jelly came from, I think it was oil miners, or something, working with grease. I think that’s a really interesting point that you’re making there about the immune cell interaction.

Asha: Yeah, it’s a huge one for my eczema clients. The acne clients will steer well clear of things like that that are film forming, but the eczema clients, they’re desperate for, like, that fake skin barrier. And so they’ll be, kind of, addicted to those products, and it’s actually undermining everything whilst they’re using them, unfortunately. But it’s one of those things where we can’t rehabilitate until they go cold turkey.

Andrew: Let’s go a little bit into treatment options here. So we’re talking about gut stuff, so obviously prebiotics, probiotics. Do you tend to use a broad spectrum? Do you tend to, sort of, pick and choose your probiotics? And can you take us through some more of the therapeutic which you use to bring down the inflammation, perhaps, I don’t know, omegas, certain fibers? Yeah, curcumin?

Asha: Yeah, for sure. So I won’t prescribe until I’ve seen testing generally, unless someone’s taking antibiotics and we’re wanting to support that. I wanted to discuss the things that have the most profound impact on people’s skin. So I’m a huge fan of bovine immunoglobulins, dairy-free. They can be used as binders but they also have many, many applications, too, obviously increasing secretory IgA, and also, but in the skin. So there’s been a lot of research around that in the realms of colostrum and lactoferrin, and we see that there’s a reduction in acne grade. There’s a reduction in sebum content, reduction in inflammatory lesions, inhibits proliferation within the sebaceous gland, inhibits mTOR, hello, enhances skin barrier, stimulates skin regeneration, and it can increase the synthesis of collagen and hyaluronic acid. So there’s nothing it can’t really do for the skin, and I have to admit that it’s prescribed for almost every single patient of mine, with great results.

Fish oil. We know fish oil is very, very well researched. I’m a little bit rogue here in that I don’t actually prescribe fish oil until I understand someone’s capacity to absorb fats because it could be putting more pressure on the system. So I would prefer to have a very well functioning gallbladder and bile flow before I’m going in with high-dose fish oil. So it’s actually not a first choice for me, but it definitely needs to be in the mix at some point because it has so many implications for acne and skin. There was actually some really significant findings from a 2024 German study which has provided some of our strongest evidence to date, so really demonstrating that many acne patients have an omega-3 deficit, and that their acne severity improved significantly when that was replenished. So we know that it’s got anti-inflammatory effects, including down regulation of proinflammatory cytokines, and insulin-like growth factor, which is very, very interesting to me. So we do need to correct the omega-6 to 3 ratio in the diet. First and foremost, that has to be addressed. But then, yeah, we really want to include that at some point for overall skin health.

One that I’ve been playing a lot with recently is, I mentioned binders and using bovine immunoglobulins as binders, but I have also been having a bit of a play around with zeolite recently. And there is actually quite a lot of evidence for zeolite, not just internally but topically. I haven’t actually played around with it topically at this point. We have to be very well aware of the quality of the clinoptilolite, and where it comes from, and what mine, and stuff like that. But it will swap out zinc and replace for toxic elements. So for me, if someone’s having die-off in their gut protocol and I’ve already got them on the bovine immunoglobulins, then I will bring in the zeolites at a quite high dose for that as a binder because it’s not gonna steal minerals like charcoal. It’s actually got a cage of minerals and it’s gonna swap them in return for toxic elements, which is very generous of it, and not just heavy metals, all toxic elements. And it has other supportive factors for the liver and things like that. So yeah, yet to try it topically, would be curious about that. But yeah, I do use it more and more to bind toxins in the GI tract.

Curcumin, yeah, is a real go to, and I am using turmeric stem cells topically at the moment as well, so that is exciting, so internally using curcumin to reduce inflammation, but also to support the polyphenol, to support the commensals. So we know that it will down-regulate inflammatory targets, inhibit inflammatory cytokines, but it also inhibits biofilm, and reduces inflammation associated with reactive oxygen species, so it’s very, very indicated for skin. Green tea is a fave as an anti-inflammatory, antimicrobial, inhibits the bacterial membrane on bacteria in the skin, reduces 5-alpha reductase, and has got a lot of research to back it as well. Berberine, I’ll use it in the context of an antimicrobial. I don’t just use it, kind of, willy-nilly. But we know that it’s got a lot of evidence to support it as well. Some studies are showing 45% reduction in four weeks, and it’s an inhibitor of the mTOR pathway as well. So if you have someone who needs that as an antimicrobial and they have acne, it’s a double bonus.

I’m gonna talk about probiotics in more detail, but a couple of others that I use quite a lot in herbs are reishi. So reishi is really fantastic for promoting antioxidants in their skin. It’s antiangiogenic. It’s induction. It reduce redness in the skin. Polysaccharides in it are very hydrating for the skin. It inhibits pigmentation via tyrosinase inhibition, and it’ll increase those white blood cell counts which are often low in people with acne. And then echinacea is quite a fave as well, so that inflammatory pathway, plus it’s well researched as well. But yeah, I can do more of a dive into probiotics, if you’d like.

Andrew: If you’ve got time. I know that you’ve got a hard stop because you’ve got clients to see, but, mate, I’ll talk for three hours with you, if you can [crosstalk 00:38:40].

Asha: I think it would be a shame not to cover the probiotic aspect, so let’s do that. So look, the research could be better in terms of acne and probiotics. It’s still limited given the scope of what it can do, but what we do have is very encouraging. So there was a study where they used it in conjunction with women who were taking the minocycline, which is very harsh on the gut. And they split them into three groups, so probiotics alone, antibiotics alone, and then a combination. The combination group had a massive synergistic anti-inflammatory effect when used together, and so it’s demonstrating that we very much need to support our acne patients when they’re taking antibiotics for their acne or otherwise to get better outcomes. But there is some compelling in vitro work showing antimicrobial effects. So, sort of, the strains we’re looking at, at L. casei, L. plantarum, L. gasseri, L. lactis, because they’re effective against those pathogenic strains of the acne bacteria. Now just remember that many of the strains of the C. acne’s bacteria are actually really essential for the microbiome, and we don’t want to kill all C. acnes. We all have C. acnes on our face. It’s the pathogenic strains that are causing problems. So yeah, while it’s early day, and they actually combine these with konjac as well for great results, which is really interesting.

Andrew: [inaudible 00:40:15]

Asha: Yeah. There’s been research into the use of probiotics topically, and that’s certainly something I use with every single one of my patients. I use prebiotics, probiotics, and postbiotics serum topically to re-inoculate the skin microbiome. But that’s very interesting because that actually has been demonstrated in literature to help with that negative C. acnes proliferation, and staph aureus biofilm production, plus better hydration and fewer porphyrins, which can be part of the acne cascade. And there’s some strains that they’ve isolated from snail slime orally and topically which is going really well, so let’s just keep an eye out for that. But I think the takeaway for me in that is that the evidence suggests probiotics work through multiple mechanisms, gut-skin axis, direct antimicrobial effects, immune modulation.

But what they can do really well is modulate insulin-like growth factor, which we talked quite a lot about today. So we know that the IGF-1 is playing a big role in acne pathogenesis, and this is where our dietary recommendations but also probiotic protocols can make a lot of impact. So we know that certain foods, like the refined carbs and dairy, are associated with increase in IGF-1. But from a probiotic perspective, when the researchers looked at supplementing lactobacillus to the fermentation of dairy that the IGF levels were four fold lower than the non-fermented skim milk. So this is telling us that probiotics are not just working locally in the gut. They’re actually modulating the systemic levels of IGF-1, which is therefore reducing acne. And so talking to people about fermented dairy, so we’re talking about the distinction between functional dairy and refined dairy, some can tolerate, some cannot. It’s a very individual thing in clinical practice. But a nice coconut kefir is always gonna be really helpful for that aspect, and supplementing with probiotics.

Andrew: Seriously, there’s so much more to delve into here. I seriously would love to talk to you for hours. I could learn so much. Asha, you really are awakening something that it’s so easy for us to forget, and that is these basic tenets of naturopathic treatment. Can I ask as a last question, once you’ve got your client’s acne under control, we’ve got ongoing therapy, you might eventually need to intervene, as you said. You get the foundations set up first, you need six months to do that, and then you might need to tweak other aspects. Tell me, that flow, how does that normally present in your patients?

Asha: Yeah, absolutely. So I say to my patients, “We need 6 to 12 months because this has probably been a long time in the making.” You’ve got that analogy of the bucket, the internal bucket, and that’s an inflammatory bucket, and into it can go stress, and poor dietary choices, and hormonal imbalances, and gut microbiota imbalances, and heavy metals. And it’s not until that bucket is overflowing that we see it come out in the skin. Because people often say, “Why did I get adult acne? How did this happen?” And I’ll explain the bucket analogy, and I’ll explain that this was a long time in the making, and that we have to really empty out that bucket. And always, always, always what I’m doing, I do believe that as clinicians our job is to educate. And my job is to educate people around their root causes of why they developed acne or a skin condition in the first place, and then the tools to manage that.

So once we’ve done the deeper work, so once we’ve done a gut protocol, or once we’ve done that liver gallbladder work, or once we’ve even done heavy metal work, then my job, I see it, has been mainly done. And during that process, I should’ve helped that person enough to understand how to maintain their skin and their health, you know, moving forward to that. So none of my clients go back to their diet the way that it was before they see me. None of my clients go back to the skin care that they were using before they saw me. They will change as a result of the work that we do together. And I do explain to them that, “In the beginning we do our foundations, and then I’m gonna take you on a journey of doing that deeper detox drainage pathway work. And then, you’ll go back to the foundations in your daily life, and that’s how you’ll maintain your skin, as a more aware, connected, educated person to create positive change for a lifetime.”

And I’m also very passionate about functional detox and detox in daily life. So along that path, we would have discussed castor oil packs, coffee enemas, dry-skin brushing, far-infrared sauna, nervous system regulation. I’m doing my breathwork teacher training in November and it’s a big part of what I bring into clinical practice, so sleep, all of those things. If someone’s skin is resolved then I say to them, “If you wanna see me quarterly, you can.” Sometimes we’ve found bigger things, like heavy metals, that we need to keep going with, but other than that, they can see me quarterly or they can just see me as needed afterwards.

Andrew: Asha, I have learned so much from our near hour together. Seriously, I’ve…wow, you’ve awakened, reawakened something in me which I’ve forgotten, and I might just say, the way that you give truly thoughtful care, like, everything that you do has a reason for doing it. And the instance I’m gonna just quickly relay is, I remember a young lady that came to see me once and I was treating her for detox. And her skin just, bang, broke out, like, really bad acne everywhere. And I just went, “Whoa, back.” I said, “Look, I can’t treat you in this scenario.” And she said, “No, no, I really want you to treat me.” And I said, “Look, really, this is surpassing me. I need to refer you on.” And so I referred her on to Rusty, love your work, Penelope. Some people will know her, where she was taken care of, in a more thoughtful manner, I might add. But it was a big lesson for me in going in too hard, and I love how you say, “I will not do that until I’ve done this.” And the reason is because you’re setting up the foundations so that your terrain is normalized, and it’s such an important aspect that we lose sight of. Well done, Asha, really, well done.

Asha: Thank you. Thank you. That’s really kind. Thank you, Andrew.

Andrew: Brilliantly depicted. I wanna see you doing a seminar on this. This is groundbreaking stuff that we all need to know, just why you do things in a certain manner. It’s brilliant work.

Asha: I would be happy to, and I love sharing, and thank you so much for having me on the podcast.

Andrew: Absolute honor. It really has been my honor. You are a true guardian of the gut. Well done.

Asha: Thank you, Andrew.

Andrew: And thank you all for joining us today. Remember, you can catch up on all the show notes. We will put as much as we can into the show notes for this podcast, and you can catch up on all the other podcasts on the Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness By Designs”.