Eczema - The Headache of Rashes
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Kara Wada, MD: Welcome back everyone, and thank you for joining us this week on this episode of the Becoming Immune Confident Podcast. Today, I am so extremely excited to welcome one of my mentors in my education to the podcast. Someone who is an internationally known expert. So Dr. Zirwas is an American Board of Dermatology Certified Physician.
He is nationally known expert who has been specializing in contact dermatitis, itching or pruritus, Atopic dermatitis and Seborrheic dermatitis for the last 20 years. In addition to his practical experience that comes from taking care of the most challenging patients, he has published over 195 peer reviewed articles, been an investigator on over 80 clinical trials, co-authored the 7th Edition of Fisher's Contact Dermatitis and has given over 200 national continuing medical education lectures to his peers.
His passion for figuring out the real, practical take home messages that we can get from the medical literature. Not just reciting the data or what the author said, but really synthesizing it and putting it in the context of how it can help our patients. Basically figuring out 'what this study really means' and how it's connected to what we already know, and then explaining it in a practical, relatable, entertaining, and memorable way.
I can't honestly think of a better guest to have on the podcast. So thank you so much, Dr. Matt for joining us and maybe you can start just by sharing how you found your way to this area of dermatology.
How Dr. Zirwas found his way in Contact Dermatitis area of Dermatology
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Matthew Zirwas, MD: Yeah. So first, Dr. Kara, thank you for having me. I love getting to talk about this stuff, so when I was a resident, I got interested in dermatitis and for your listeners, dermatitis is a general term that just means inflammation of the skin, but specifically, Spongiotic dermatitis is the medical term for eczema.
And so I got interested in eczema as a resident and what you learn as a resident, 20 years ago, 25 years ago, was there's atopic dermatitis and that starts in childhood, and then people get allergies and maybe it'll go away, but then maybe it comes back when they're an adult. But so if you get an adult with eczema, if they didn't have it as a kid, it's not Atopic dermatitis. Right now, first, I'm gonna tell everybody that is completely wrong. We now think about the disease totally differently, but as a resident, that's what we learned. And so I would see all of these people as adults who'd never had eczema as a child, never had allergies, but had Spongiotic dermatitis. And I said, "Oh my gosh, these people must have contact dermatitis".
So I'll become a contact dermatitis expert and contact dermatitis entails testing people for: Are they reacting against the ingredient in their shampoo? Their laundry detergent? Their whatever, looking for a specific cause and what I learned pretty quickly was that the vast majority of people, no matter how much we tested them, we couldn't find anything. And if we did find something, maybe there was a one in three chance it would actually get better whenever they avoided it. But, so it became lots of like just trying to figure this out and trying different things. Basically experimenting on patients. Because we didn't have anything that reliably worked.
And so it was maybe it's your microbiome, so let's try this, and then let's try that. And maybe it's this environmental exposure and maybe it's this dietary thing and let's try this medicine and try that. And I got better at helping these people, but still not great. I was better than anybody else, but there were still tons of people that I couldn't do much for. So that was really how I got interested.
And then in 20 17, medication came on the market called Dupixent. And that was just life changing for me and for my patients, right? Because what's particularly unique about Dupixent in this setting is that it's a pretty specific drug, so it works for atopic conditions but it doesn't work for contact dermatitis.
And so one of the questions that always happened for these people who had eczema was okay, you didn't have it as a kid and you don't have allergies, so I don't think it's atopic dermatitis. We patch tested you and you didn't have many positives or you didn't get better. So I don't think it's contact dermatitis. So I don't know what you got, right? You don't think you have atopic derma? I don't think you have contact, I don't know you got eczema. And so when Dupixent came out, those patients technically meet the American Academy of Dermatology criteria for atopic dermatitis. So now those criteria say that the essential features: it's gotta be itchy, chronic, eczematous, and spare the groin and axilla. So if it's those four things and you don't think it's contact dermatitis, or scabies or some other reason, then it's atopic dermatitis. So according to those criteria, pretty much chronic Spongiotic dermatitis is atopic dermatitis. And I was, at the time, I was like, "No, that is not, this is ridiculous, I've tried everything else with these people, I've tried Dupixent, I don't think it's gonna work". Son of a gun if it doesn't work phenomenally.
And so the last six, seven years have been by far the most exciting part of my career. Because there was this change of how we think of atopic dermatitis, and so now I'm like, oh my God. Okay, all of these adults who first got these itchy rashes as an adult, never as a kid don't have other atopic comorbidities. I think they really do have atopic dermatitis. How does this work? Why does it look so different compared to little kids? It's always the same. They get it on their face, their hands most of the flexural areas, they get food allergies, they get asthma, it's always the same in all these children and adults. It just looks different, it doesn't act the same, it doesn't look the same, but I think it's the same disease and getting as other people. I don't have a lab. I'm not doing these basic researchers, those kinds of things, I'm just reading everything else that everybody else is publishing and trying to put the pieces together. And we've been able to put 'em together especially in the last six months, it's just been like a bunch of things clicked at once and now we understand Adult Atopic Dermatitis so much better than we used to. And that is just so much fun.
Matt Zirwas' definition of atopic dermatitisz
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Matthew Zirwas, MD: And so the the first thing that I like to talk about with this is what's Matt Zirwas' Definition of Atopic Dermatitis. And so first, for everybody listening, so the way that you think about this first, so the word Eczema is like saying Headache. The question isn't, "Do you have eczema?" The question is, "Why do you have eczema?". If you go into the doctor, "My head hurts". And if you finish the visit and the doctor was like "You have a headache". You would be like, okay, I could've figure that out myself. So the quick, "Do you have a migraine headache? Do you have a cluster headache? Do you have a brain tumor?"
And then that tells you more about how you're gonna treat it and what's causing it. So eczema, the equivalent in this headache analogy would be Atopic Dermatitis is like saying you have a migraine headache. It's a specific type of eczema. And the way that I define Atopic Dermatitis is an excessive epidermal inflammatory response against non-specific environmental triggers. And so the things that are most probably the most interesting and important part in there is Non-specific environmental trigger. So if there's a specific environmental trigger, it's contact dermatitis or it's scabies or there's a specific thing we can identify. That's the thing. You get rid of that and you will get better.
Kara Wada, MD: The root cause.
Root Cause of Atopic Dermatitis
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Matthew Zirwas, MD: The root cause. Now, so in atopic dermatitis, the root cause is not some specific exposure. So here's the way that I explained it to all of my patients. So for anybody who's watching the video, you can see what I'm doing with, for anybody who's not holding my hand up, right hand up as if I was being sworn in. Your skin is supposed to look like this, and anything that gets on your skin, can't get in. And so, you're fine. Doesn't matter what gets on your skin. If you have atopic dermatitis, it means your skin looks like this. And so now I've spread my fingers apart so there are gaps between them. And so instead of it being things on your hand, can't get past those fingers, when now the fingers are spread apart, anything that gets on your skin can get in. Now, then what happens? Your immune system overreacts to this stuff. And so the root cause of atopic dermatitis is the combination of gaps in your skin that are letting things from the environment in, and then your immune system overreacting to them.
And so trying to manage atopic dermatitis, the first thing that any normal person would think is "Let's figure out what's getting in. And we'll get away from it". The stuff that's getting in, your own sweat, right? Pollen in the air, air pollution, and there's been a huge amount. Air pollution is such a huge factor in your type dermatitis we didn't know before. Your cutaneous microbiome: just wearing clothes, right? We've always known certain fabrics. So wool is gonna make atopic dermatitis worse, residual laundry detergent in your clothes, just bathing every day. So doesn't matter what soap you're using. Just the fact that you're bathing in generally treated water, so that's got calcium and magnesium or chlorine in it.
None of those are things something our skin evolved for. Skin didn't evolve to be exposed to warm water or hot water every day. But it's not even the temperature of the water. It's just the stuff in the water to rapid changes in temperature. Our skin and humidity. Our skin didn't evolve to be inside and it's 70 degrees and then you walk outside and now it's 30 degrees. 10,000 years ago, that never happened. Or it's 70 degrees inside in a 100 degrees house never happened. So these, there's all of this environmental stuff. To try and figure it out., You can't.
Skin Barrier: It's Not About what's Getting in, It's About Can We Close Those Gaps
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Matthew Zirwas, MD: So it's not about figuring out what's getting in, it's about can we close those gaps up? And can we reduce the immune system's overreactivity of the things that you're getting exposed to and fortunately now we have drugs that work really well, but first just getting people to be able to understand that.
Now to start to get into some of the nitty gritty of this. This is just so freaking cool. This, right? When patients used to ask, "What, I'm 47, why did I get this? I didn't change anything. I didn't move. Why? I didn't change my diet. I didn't change my job. I didn't change what I'm wearing. I didn't, why did I get this?" So here's was the fascinating study that was like the light bulb that went off. So we used to answer that, "You were always genetically predisposed and just over time as you got older, your skin got weaker" which patients hated that answer and it actually wasn't the right answer. We have a better answer now.
So there was just this study done in the uk. So the UK Biobank, so they have 500,000 people that they have genetic sequencing on. And they were looking for what are the genetic markers of Adult onset Atopic Dermatitis, and what are the environmental interactions with those genetic findings. What they really showed was that atopic dermatitis in adults, the genetic component is really small. So there's much less genetic skin barrier issues with adult onset atopic dermatitis, but environmental issues play a huge impact. So again, the two big ones chronically: air pollution and water hardness.
Why did your skin get these gaps?
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Matthew Zirwas, MD: And so now that I start to put this together, whenever I talk with patients about why did your skin get these gaps? We now much more think of it as it's the sort of the natural wear and tear from all of the different chemicals you've been exposed to. And by chemicals, air pollution, residual laundry detergent, calcium and magnesium in the water that you're bathing in, like just the general stuff. And you weren't overexposed to it. It's not "Oh my God, You got to, You need to", it's just normal life.
Like for a dermatologist, we think of skin cancer. Why do I get skin cancer? Because you've been getting a little bit of sun just constantly over your whole life and eventually that damaged your skin enough that you got a skin cancer.
You've been getting a little bit of exposure to this stuff and it's been slowly damaging your skin to where now the gaps got big enough that this stuff's getting in, right? So I think that what we are gonna find out over time is that different people, so first obviously, there is some genetic component because not everybody gets atopic dermatitis and everybody is exposed to a similar environment. So there's some genetic component to your skin getting damaged by stuff. The second part is gonna be which environmental triggers are relevant for a given individual and I think we're eventually gonna find out that's genetically determined. Some people are more reactive to Malassezia yeast. Some people are more reactive to pollens, in particular pollens. Some people are more reactive. We're gonna find out that there are different triggers for different people and I think that's probably gonna be largely genetically based.
Intestinal Microbiome and Immunological Reactivity
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Matthew Zirwas, MD: But even that, the immunological reactivity, we now think of as being at least significantly driven by the intestinal microbiome. So there have been some studies looking at the microbiome in people with adult onset atopic dermatitis versus the intestinal microbiome and people with pediatric onset atopic dermatitis. They're different, the abnormalities of the microbiome. So now, when the other answer that patients really love now for the, "Why did I get this?".
So it used to be that patients would say,
" I've noticed when I eat this food, I get worse"
and as the dermatologist should be like,
"It's been shown that food allergy is not the cause of atopic dermatitis",
"But I think it's food. I know it seems that way".
And eventually they're like,
"Fine, we'll go send you to an allergist. They'll test you, tell you're allergic to seven things. You'll avoid them. You won't get better. Then you'll come in and complain about that. But fine, we'll test you".
Food's Significant Role in Atopic Dermatitis
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Matthew Zirwas, MD: But we now understand the patients were right. So food is playing a significant role in atopic dermatitis, but it's not food allergy. So now after I've gone through my this stuff's getting in this, we're gonna do some things to close up the gaps. Then we're gonna do some stuff to get your immune system to not overreact as much. Now, whenever I'm talking about that part, I will proactively bring it up. "So have you noticed that some food sometimes seems to make you worse?" "Oh, yes, absolutely".
" It's been really interesting. We've learned that food plays a huge role in atopic dermatitis. But it's not that you're allergic to any foods. It's that, the modern diet with the processed foods, the food additives, the food preservatives, the antioxidants, the food colorings, the hormones, the antibiotics, the pesticides, all of that has taken the natural, healthy bacteria in your intestines and gotten them out of balance, and that irritates your immune system. And one of the ways that shows up is your immune system being overreactive in your skin. And so the thing is, it's not that there's gonna be certain foods you need to avoid, it's gonna be that we need to get those bacteria back into balance. And the way we're gonna do that is with a probiotic".
So there are two things in particular that I do that there's randomized control trial showing that they help. Do I think they help enormously, I'm not sure, especially in people with moderate to severe atopic dermatitis where it might be just so bad that we need to use a pharmaceutical.
But the so right. First lemme give you, so lemme give you what my spiel is with a new patient, right?
"Ms. Smith, you've got eczema, but eczema's saying you got a headache. The question is what kind of headache? And you've got something called atopic dermatitis. Which is like saying you got a migraine headache.
And what's atopic dermatitis means is your skin is supposed to look like this, where nothing can get through it, it blocks anything that gets on well, your skin looks like that, and it's done this over the years, just from the chronic damage and irritation to your skin from air pollution and pollen in the air and bathing every day. The water hardness and wearing clothes and residual laundry detergent has slowly damaged your skin. And now things from your environment and the same kinds of things, not things you can get away from: your own sweat, the natural bacteria that live on your skin. Again, the pollen in the air pollution, the calcium and magnesium and chlorine in the water, you bathe in those things are getting in and making your immune system over react.
Now there are a couple things we can do to try and get to the root cause of all of this. So first we're gonna have you start taking a couple of supplements. And, all right, so now I'm stepping out of the room for a second talking to you the supplements that have some reasonably good data to back them up.
Number one, oral ceramides. So ceramides are one of the key natural oils in your skin that are probably the most important aspect of having good barrier function. And so there's some data that taking ceramides by mouth actually helps your skin barrier function. So what I will do with that is I'll have people go to Amazon and the ingredient is called Lipo Wheat. L i p o w h e a t. I have no conflict of interest. It's an ingredient, not a product. So I just have people search that in. If you put that in Amazon, bunch of products will come up that have it. And basically I tell people, get the cheapest one cuz Lipo Wheat is a branded ingredient. So if it has Lipo Wheat in it, I know it's got the right stuff that has some data to back it up.
So I do that. A study just recently came out as well saying that high EPA fish oil also helps some with atopic dermatitis. Fish oil is good for people in general and both of these are pretty cheap supplements. So again, I'll tell people, go on Amazon. Look online, search for high epa fish oil. Both of those are relatively cheap and easy, and I think of those as the two things we can do to try and close those gaps up. And there's some data for both of them .Then, "All right, so Mrs. Smith, we're gonna have you take these two, we're gonna have you take these two supplements to try and help close these gaps up. And then we're also gonna have you take a probiotic to try and get those natural bacteria back into balance. And the probiotic that I have people take, again, there no conflict of interest. You get it on Amazon it's called Now, n o w probiotic 10. And that comes in 10 billion, 25 billion, 50 billion. I have people get the 25 billion. But that one has, several studies that are randomized, double blind, placebo controlled trials, looking at different strains of probiotics, in Atopic Dermatitis. And that one has several of the strains that have been shown to be helpful and it's cheap, so it's about eight bucks a month.
The biggest thing with probiotics that they always tell people, and there's a lot of confusion around this, you have to take probiotics with food. So the one study we have about this showed that taking it with food, you get better delivery into the intestines. And that intuitively makes sense because if you think about where probiotic, where the idea of natural healthy bacteria intestines came from, it was cuz we were walking around in the woods, like picking stuff up off the ground and eating it and it had bacteria on it. You weren't taking the bacteria without the food. So it makes sense that you take probiotics with food. So we do the probiotics to try and get the immune system overactivity calmed back down- the inflammatory component. And so those are the two things that we're going to try and address the cause of the Atopic dermatitis.
Now the other thing that I though tell these people is, look, it took 40 years for your skin to get damaged enough and the bacteria in your intestines to get out of balance enough for you to get atopic dermatitis. So these things might take a while. It might take six months a year. Don't expect you're gonna start taking these and your eczema it's gonna be better in a couple of months. Maybe it will be but don't expect that. And so in the meantime, we need to treat you with medication to get your eczema better quickly. And fortunately for you, we have medications now that are not steroids. They're not something where you're just going to use it, but you can't keep using it so your eczema it's gonna get better and then come right back. We actually have medications now that you can keep using long-term that are gonna work really well, but we're also gonna be putting you on these supplements and probiotics and maybe you won't have to stay on the medication forever. Most people do, right?
So now I'm talking to you. Most people do. If we stop it, that eventually comes back. But I have had patients now who we treated them, got them better. Let their skin recover, gave them the probiotic and the supplements, and they've now been off of pharmaceuticals for a long time and maybe their eczema is gonna come back eventually, but when I say maybe we'll be able to get you off of this eventually that is a true, maybe we are gonna be able to, maybe we can actually get your skin better. And just all of that, right? So the whole spiel of how we talk to patients about atopic dermatitis now, the idea that we really understand what's happening in the skin on a high level, right?
So when you start to get down into the weeds of right the more which cell types, which cytokines, T regulatory cells, T skin-resident memory cells. We still think what we're gonna find is that Atopic Dermatitis is a heterogeneous disease. That there are certain cytokines, IL-13 usually seems to be playing a big role. IL-13 seems to be playing a big role. Skin resident memory cells, skin resident regs like seem to all be playing roles. But I think the nuances are gonna be different and there's still gonna be a lot of work. We're still, I think 20 years away from really understanding the fundamental which cytokines and why but from a big high picture level, where's the barrier defect coming from? And kids, it's genetic and adults, it's environmental. Where's the immunologic general overreactivity coming from, part of it's genetic, part of it is again, environmental seems to be the best answer we have right now is intestinal microbiome is the main environmental part that we can deal with. But from a high level, we now understand the disease much better. And we also have drugs that work, right? We have drugs that are safe for long-term use that, that actually work really well.
It's been so much fun. Starting to understand one of I've call 'em diseases of modernity. So in the modern world, right? There's so much more atopic dermatitis than there used to be. And we didn't understand why. Now we're understanding better. Okay, it's been the air pollution, the increased general exposure of the skin to chemicals and then the intestinal microbiome is, we've gotten to more and this is right, this is a big leap for me to say microbiomes abnormalities because of food processing and all that, but that makes sense to me. Our food supply has more processing, more chemicals in it than it's ever had before. So we now have a way to draw together big picture things of what's been happening in the world. Generally just more exposure to chemicals and generally more exposure to what you would call non whole foods. And those two things on a very low grade, long-term level lead to atopic dermatitis in adults. And that's makes sense, right? And it gives us some targets for what to do to try and get people better. Fortunately we also now have, like I said, medications that work and so we can get people relief while we see if dealing with the underlying things helps. That's my overview of kind of where atopic derm is nowadays compared to where it was six, seven years ago.
Kara Wada, MD: The way I conceptualize too this idea of using both medications and lifestyle as you're explaining, it's like a fire containment system we'd have in like our buildings, we have the sprinkler system, we have the fire extinguishers around we have flame retardants, which actually we don't wanna be around, but they serve a purpose. But sometimes we do have to call the fire department in and that's where some of these pharmaceutical medications are really helpful to get things under control so that then we can use the probiotics, the diet with increased amount of fiber that's gonna feed those healthy gut bugs decrease kind of our other exposures to other lotions and potions and things that aren't serving us well and let those things also take hold in that healing process.
Do I need moisturizers if I have eczema?
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Matthew Zirwas, MD: And you bring up a really interesting thing. So it's one of the things that kind of often drives me a little bit nuts about kind of modern medicine, right? So all of the guidelines from every organization, known to man for atopic dermatitis would be like, "Oh, moisturizers are the fundamental, blah, blah, blah". And I was like, "I don't know that I've ever seen any data that says moisturizers with adult atopic dermatitis actually help all that much". And it wouldn't shock me to find out. That they make things worse over time, right? Because they're natural oils, maybe, almond oil, apricot oil, things like that. Okay very natural. But still, it's not 10,000 years ago, our ancestors had almond oil, or our ancestors had apricot oil like to rub on their skin. They didn't really, they didn't have any of that stuff. So my patient was like, "what moisturizer should I use?" I'm always like, "I don't really care if you use it. If you do, try just trial and verify what you want. But I'm just never that convinced that moisturizers do any good. And it's certainly possible to me that over the long term they're harming people's skin and making them more susceptible to atopic derm. Very controversial opinion there, by the way for many of my colleagues who might be listening to this, who are having a stroke right now, I apologize.
Kara Wada, MD: What I though have started to tell people is to simplify. Scale back. There for one, it's gonna cost you less money. Number two, you are then exposing yourself to overall less of that burden of other ingredients that you could potentially become sensitized to. And I encourage people to even use less of the surfactants or the soaps that are washing off those natural oils. Use it in the areas that get smelly, those areas that get sweaty and smelly. Absolutely we want to be able to spend time with you in real life in the same room. But as you mentioned, earlier in the conversation, 10,000 years ago, we weren't bathing as often and it probably was in the cold stream or the lake.
A Dermatologist's Rules of Bathing
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Matthew Zirwas, MD: Yes. And that's what I tell what I tell people about bathing is you can either use hot water or soap. You can't use both. Now, hair, face, armpits, and groin, hot water and soap, fine, right? But for the rest of your skin, the way that I think about this, those natural oils in your skin, think about them roughly the consistency of butter. So then I want you to go do a little experiment. Go home, rub some butter on a plate, and then try and wash it off with cold water and soap. You can't, you're just gonna smear the butter around. Okay. Now don't use any soap, just use hot water. You don't even need the soap. The hot water just melts the butter and it rinses away. So with hot water, you're actually are removing oil, getting clean. If you use hot water and soap together, you're removing too much.
And so it's either, if you wanna use soap, okay, fine. You gotta get that part of your shower's gotta be cold. Can't even be lukewarm in my opinion. It has to be cold, if you wanna use soap. If you don't wanna use soap, if you wanna get a hot shower, just don't use soap. I'm either one, I'm okay with, and if you're filthy and once in a while, you know you're not gonna, but even if you've just had a hard workout, the hot water by melting that skin surface lipid, you still get the removal of the lipids right, and that superficial cleaning that you need. So hot water or soap, but not both is what I tell people.
Kara Wada, MD: I love that now, if I could just keep my seven year old from climbing the pine trees. When you were talking about being filthy, I had this visual of her earlier this week. They started camp and she was like covered head to toe and tree sap and it was quite the endeavor to get that off. But generally yeah that's the approach we've taken with our kiddos too, really to try to keep their skin barrier intact. And one of the big highlights of our annual national allergy meeting several months ago was really talking about this overarching concept of the Epithelial Barrier Hypothesis, which is exactly what you're describing.
These things that we're exposed to in our environment and throughout our lives that are essentially like chinks in our armor, whether it be our skin, as in the case of the soaps and the pollution and everything you mentioned, but also the role of those additives in our food, the things we're ingesting when our dishes go through the rinse aid cycle of the dishwasher, the damage that does to our gut lining add some additional kind of science and credence to what you were saying about, those impacts on our gut health as well.
Matthew Zirwas, MD: Wait a minute. The rinse aid stuff, I'm trying to think about this, this makes some sense. So that is probably highly like hydrophobic and is the idea leaves a little bit of residue that then dissolves some of our intestinal lining?
Kara Wada, MD: Yes. So it's interrupting and changing that mucus barrier between that's generally providing some distance between the food, the microbes, and the immune system. And so one of the working hypothesis is, these commercial dishwashers really came into popularity in the 1980s and follows. And so the time course in that being at least part of the puzzle as to why we're seeing this really dramatic increase in especially food related..
Matthew Zirwas, MD: Eosinophilic esophagitis.
Kara Wada, MD: Absolutely. In addition to its implications in autoimmune disease as well.
Matthew Zirwas, MD: In the Rinse Aid thought. I'm still okay to use my dishwasher. I just shouldn't have the Rinse Aid in there. Or is that even the dishwasher? We're a little concerned..
Kara Wada, MD: No, I'll send you the article. The thing that's really hard is a lot of the places where when we're going out to restaurants, for instance, it's used in their glass and dishware. So we're getting it. In small amounts really do have a pretty significant impact. It also is present in some of our home. Like I checked my pouches that I get from the local Sam's Club kind of thing and it looked like they're in there as well. So I'm on the lookout for some options that are gonna work better. The real issue is figuring out some that are more natural, that work with your water hardness. As you mentioned, the amount of chemical like calcium and magnesium, calcium, magnesium, different dissolved solids within our water system really changes how that interacts not with our skin, but also our soaps and I've been reading the reviews.
Matthew Zirwas, MD: Yeah. Interesting. Man, so that's now getting added to my little spiel for the stuff that's upsetting that intestinal microbiome. Yeah.
Kara Wada, MD: The reality is we are living in a modern world, and as a busy mom of three kids, seven and under, we have a ton of dishes and the reality is I'm not gonna stop using my dishwasher. There are some things I am absolutely like excited and willing to do, but I think there has to be, at some point, some of a discussion about okay, balance and then what I really would love for the data to show us is, will we get to that point that you were mentioning where we can say, "Okay, I take this little test and it says for me, Air pollution is a bigger issue than the dishwasher situation" or what have you, so that then I can personalize my time, effort, money into things that are going to be higher yield. Wouldn't that be cool?
Matthew Zirwas, MD: Yeah, that would be super cool. Yeah, exactly.
Kara Wada, MD: We'll get a little app.
Matthew Zirwas, MD: Not a bad idea, not a bad idea.
Kara Wada, MD: Thank you so much, Dr. Zirwas for taking time out your busy schedule to share all this knowledge. I am actually going to make this required viewing for our fellows so that they're all up to date.
I think it will be great for them and we'll get the most mileage out of your time and expertise. Is there anything that would be helpful for you to share with our audience about ways to connect or if they're interested in your work
or?
Matthew Zirwas, MD: Not really? I keep a relatively low profile out there other than doing things like this.
Kara Wada, MD: We'll get you to start a YouTube channel one of these days.
Matthew Zirwas, MD: All right.
Kara Wada, MD: You'll give Dr. Sandra Lee a run for her money.
Matthew Zirwas, MD: Yeah. Pimple Popper MD. All right, thank you, Dr. Kara.. So I appreciate another one with you at some point.
Kara Wada, MD: Sounds great. Take care. Be well. All right.
Matthew Zirwas, MD: Yep. Bye.
Kara Wada, MD: Hey, everyone. I am going to ask you once again to go into Apple podcasts and submit a review of the podcast for me.
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Thank you so much, Dr Lex Rx and Amanda Katherine. I really appreciate the feedback and the review.
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