Dirty Looks

Introduction

Learning to Love Your Good Bugs

As a kid, I was always covered in dirt. I loved to dig in the earth, and I loved frogs and grass and bugs. Once, I even hid a snake in my overalls, which caused quite a stir when my kindergarten teacher discovered it! I was a blond-haired, blue-eyed, rosy-cheeked free spirit who dirtied a set of clothes about as fast as I could change into them. But that was all before I got sick.

You see, that carefree little girl spent her tenth year of life in and out of the hospital. The environment was sterile and cold. I was afraid. I was in pain—awful, chronic pain. The doctors didn’t know how to help me. My parents didn’t know how to help me, either.

It turns out that a bad bug—a parasite—had made its way into my intestines from fish I had eaten while on a family vacation. It wreaked complete havoc on my body. Even worse, the doctors couldn’t find it. They tried to treat me with antibiotic after antibiotic, which eventually destroyed the healthy bacteria in my gut, leaving behind an infectious type of bad bacteria called Clostridium difficile, or C. diff, which made me even sicker. This horrific combination of circumstances, in which one bad microbe was followed by another, hurt my body and changed my life.

But all was not lost, because as I sat in the hospital, I started to think. Even as a ten-year-old, I could reason, explore, ask questions, and try to make sense of things (maybe it was my way of coping). I knew that where we have bad, we always have good. It’s the age-old balance between good and evil. So where we have harmful microbes, we also have helpful microbes—although the beneficial ones that had been slaughtered in my gut by antibiotics could no longer help me. This thinking process is where the happy ending to my story began—it started me on a passionate lifelong quest to find the answers to the question of how to create and maintain a balance between the heroic and villainous microbes that live in our bodies and on our skin.

From the moment I was released from the hospital, I was inspired to make my body strong and healthy. I was concerned with the obvious outward signs of health, such as glowing, radiant skin, as well as the hidden, invisible indicators of health, the ones that lie deep beneath the surface. This is where my passion for health and beauty from the outside in and the inside out was born. And this is where my fascination with the science of the microbial bugs that exist on our skin and throughout our bodies, including in our gut, initially began, because I experienced this balance (or imbalance) firsthand. Who better to investigate the depths of this area of science than someone who fought for her life because of it?

I succeeded in what I set out to achieve: a robust body that emanates health. Now I help others achieve that goal. In so many ways, I am still that happy and curious rosy-cheeked girl who loves nature. But now I’m also a doctor who has found a lot of answers to those lifelong questions. My curiosity about microbiology has only grown fiercer now that science is finally grasping the magnitude of the influence that the hidden microbial world within us—and on us—has over our health. And this dazzling new science shows definitively that these invisible bugs have a lot to do with how we look. I now know, as you’re about to learn, that even on my best day, I have microorganisms in the form of bacteria, fungi, viruses, and even mites living all over my body that support my health from the inside out and give me that “Bowe Glow.” And even on your best day, you’re a “dirty” human being, too, whose health and appearance hinges on those bugs! (And if you’re not having your best day now, read on.)

Learning to harness those things that make you “dirty” will help you radiate a healthy, beautiful glow from the outside in and the inside out. Your skin is a window on your overall health. It “speaks” to the other integral parts of your body through something called the gut-brain-skin axis, a pathway that you will get to know and understand in these pages. This groundbreaking science has become my life’s work and has earned me recognition among my colleagues and among international thought leaders. Now let’s take an expedition together to find your most luminous skin and overall wellness using the best cutting-edge science and tools available today. Like me, you’ll learn to love your good bugs and harness your body’s full potential. Let’s show that ten-year-old little girl in the hospital bed that the story turns out beautifully!

THE SECRET TO GREAT SKIN

Take a moment to think about your skin. Find a mirror, if that helps. How does your skin feel and look? How do you feel about it? What do you think it says about you? Think of your skin’s appearance as a reflection of your overall health—how healthy do you look?

Within seconds of meeting a new patient, I can use my derm superpowers (well, years of extensive training and developing expertise, but that doesn’t sound as cool) to determine her overall health simply by examining her skin, hair, and nails. Is she diabetic or prediabetic? Does she eat a Western diet laden with processed sugars and refined carbs? Is her life overscheduled and full of constant, unremitting stress? Does she suffer from obsessive-compulsive disorder? A dysfunctional thyroid? An imbalanced hormonal system? An autoimmune disorder? Insomnia? Does she have a history of frequent antibiotic use, either orally or topically or both? Is she overly hygienic, scrubbing her skin with harsh cleansers and facial brushes? Is her gastrointestinal system in need of serious repair?

My patients come to me hoping to get the Bowe Glow. Too often, they believe they’re just a scribbled prescription away from a cure for any of the Big Four—acne, rosacea, eczema, and premature aging. But there’s so much more than drugs, topical lotions, or laser beams to this story. Every day I have the privilege of interacting with smart, health-conscious people who try to maintain their looks and health as best they can, but they often miss the mark because they don’t have access to eye-opening knowledge that is still mostly buried in the trenches of scientific literature. But the good news is that with this book, I’m giving you access to this information and grounding it in my expertise and years of experience treating thousands of patients. And here’s the secret: the road to a beautiful glow begins with simple lifestyle habits that support the gut-brain-skin relationship, which is the soul of radiant skin. More specifically, I’m referring to the bonds between the body’s good bugs and the brain and skin.

You’ve probably heard about the human microbiome by now, but trying to fully understand it might still give you pause. Much has been written in the past few years about the microbiome—the friendly microorganisms that support our health and share a powerful, mutually beneficial relationship with our bodies. The term microbiome comes from the combination of micro, for “super small” or “microscopic,” and biome, which refers to a naturally occurring community of life forms occupying a large habitat, in this case the human body. When I began to study microbiology as a junior-high-school student, nobody could tell you what a microbiome was; today, microbiology encompasses one of the hottest fields of study, and I’m proud to be a part of it. We are at the very beginning of an exciting journey to understanding—and leveraging the power of—the human microbiome.

The mini ecosystem that comprises a human biome includes a diverse collection of microorganisms, mainly bacteria, fungi, and viruses. The bacteria that thrive in our intestines are especially important. Their function in our health and physiology is so critical that they may affect a wide range of biological processes and play a role in everything from the efficiency and speed of our metabolism to our risk for diabetes and obesity. This is to say nothing of their potential role in our moods and our likelihood of suffering from depression, autoimmune disorders, and dementia. Perhaps you have heard about some of this in the popular health media. But there’s another connection that you probably don’t know about: the “last mile.” This is the indelible, incredible link from the brain to the skin. Indeed, what’s going on in your gut right at this moment is determining not only how your brain performs and responds to signals from the body about its current state and needs but also what your skin thinks and how it performs. This gut-brain-skin alliance is, frankly, profound and breathtaking, as this book will show. And yes, the skin can “think” and “talk” to the brain: it’s a two-way street. In fact your skin actually contains the same number of cells as sixteen human brains!

Researchers first discovered this relationship more than one hundred years ago, but it was forgotten until recently. Today the gut-brain-skin axis is among the most thought-provoking areas of study, and I believe it represents a revolution in our field—not least because it equips us dermatologists with a breakthrough approach to the way we think about the skin. For the first time, we can envision a future in which we aren’t just chasing skin issues that are spiraling out of control, we’re also finding ways to get to the root of the problem. We’re stopping the proverbial match from being lit in the first place.

I played a major role in rediscovering this link, having spent years in the lab counting bacterial colonies in a petri dish whenever I wasn’t poring through databases looking at epidemiological data to support my suspicions. I loved studying bacteria and figuring out what they could do—both to help us and harm us. By the time I’d chosen dermatology as a specialty, I was determined to make the connection between the secret world of microscopic bugs and the outer world of skin’s appearance. Which bugs could benefit skin health? Which could harm it? I even coinvented a patented acne treatment that uses a substance isolated from a certain bacterium. This patent was filed through the University of Pennsylvania with my research mentor, Dr. David Margolis. That’s right: we can now use good bacteria to fight bad bacteria in the battle against acne, which can be driven by a particular strain of bacteria. I’ve shared my research and theories with my peers internationally through numerous scientific publications and lectures. And in 2017, I was humbled to receive the American Academy of Dermatology’s presidential citation for this work.

Too many people suffer in silence with their skin conditions because they lack access to the kind of information I am going to provide in this book. I can only reach so many individuals in my private practice, many of whom are in the public eye daily. Their livelihoods depend on looking good, but they shouldn’t be the only ones fortunate enough to have flawless skin. With this book, I bring hope, health, and beauty to as many people as possible. That means you, no matter what you do for a living or where you live.

SKIN TELLS THE TRUTH: YOU ARE WHAT YOU EAT

You might be surprised to find that food is at the core of my program. But don’t panic: I won’t ask you to do anything drastic like totally give up chocolate, alcohol, bread, or coffee if those things bring you joy. I trust you’ll find the dietary protocol outlined in chapter 6 to be refreshingly delicious, inspiring, inviting, and, above all, doable.

Contrary to long-held beliefs in my field, diet, first and foremost, determines the quality and appearance of your skin. Food provides information for every cell that makes you, well, you. Everything you eat becomes part of not only your inner cellular makeup but also the outer fabric of your body. In fact there’s no more direct way to change the health of your body’s inner and outer ecology—its microbiome—than to make specific shifts in your dietary choices. Yes, this probably goes against everything you’ve been told about the relationship between diet and skin. Have no doubt. The idea that food is arguably the most important factor in personal health, including the health of your skin, is old news gaining new life in our modern medical world.

When I was in medical school, and even during my residency training in dermatology, we were taught that diet had no impact on the skin. All the major dermatology textbooks stated that the exception was in cases of severe malnutrition, which were exceedingly rare in developed countries such as the United States. Textbooks, lectures, and reputable authorities such as the American Academy of Dermatology told us that if a patient suggested that what she was eating or drinking had any influence on her skin, we were to dismiss that notion as a myth. This was the scientific dogma of the time, and it was based on research conducted and published by physicians who were revered as giants and geniuses in our area.

But what I was experiencing with my own skin, and what I observed in my patients, didn’t seem to fit with this alleged fact. So I approached my mentor, who also happened to be the chairman of the department at the time, and I presented him with my skepticism. Looking back, I can’t believe I was bold (crazy?) enough to think that I, a young resident in training with barely any real experience under my belt, could take on such a monumental challenge. But I couldn’t ignore what my body was telling me and what my patients were sharing with me every day.

My mentor advised me that if I was going to question the word of these highly respected authorities—lionized experts, really—in my field, I had better develop an incredibly compelling argument to support my theory. With a rebellious spark in my belly, I went back to the peer-reviewed scientific literature and dug deep, reading journals from all fields of medicine and nutrition and going so far as to have several international studies translated into English. I mined the few studies published in the late 1970s that were often cited as proof that diet had no impact on the skin, and I carefully dissected them, finding major flaws in their design. In fact if judged against the rigorous criteria by which journal submissions are considered today, these articles would never even have been published!

After many long days and late nights, I wrote a controversial paper that asserted the idea that diet does indeed affect the skin.¹ Armed with compelling evidence, I laid out the case that acne is exacerbated by diets loaded with sugar and refined carbohydrates. I also called out the fact that some dairy products trigger acne, and I hinted at the positive effects of omega-3 fatty acids and dietary fiber. Ultimately my paper was published in one of my field’s most respected journals, heralding a new era for understanding skin health within the context of diet. And my mission didn’t end there. I took to the lectern, speaking again and again on this topic, and over the years I published even more studies further supporting my hypothesis—a belief that was soon becoming indisputable fact. Although most of my peers were initially skeptical, as any good doctor should be when presented with new and competing data, I found increasingly that my dermatology audience was receptive to my message. Eventually other thought leaders emerged, contributing to the literature and spreading their own observations and research on how certain foods and beverages affect the skin. The data only grew bigger and more extensive and impressive. No one could turn me and my ideas down anymore.

Finally, for the first time since the late 1970s, dermatological textbooks, resources, and guidelines are being revised to reflect this concept. If a patient goes to her dermatologist with a hunch that certain foods are making her skin condition worse, not only can the dermatologist acknowledge that she is probably right, the doctor can also go so far as to offer evidence-based advice on how the patient can tweak her diet to benefit her skin (less sugar, milk, and processed foods; more fibrous, colorful vegetables, fatty fish, and antioxidant-rich fruits). I’m thrilled not only that my peers have accepted this concept as fact but also that laypersons and media are listening with open ears. This “new” fact could not have emerged at a more critical time.

WELCOME TO A NEW ERA

The field of dermatology is changing radically as a result of two immense forces: an epidemic of skin disorders in a world where powerful drugs such as antibiotics are losing their efficacy, and new findings about the power of the microbiome on skin health (and all health, really). Skin issues are the cause of more than 42 percent of all doctor visits.² No doubt this staggering statistic is largely attributable to the fact that you can’t hide from your skin. You wear your illness for the world to see, and unless you’re going to cover yourself up indefinitely or refuse to leave the house (two impractical, depressing prospects), you’re going to seek help. Such conspicuous imperfections can have a colossal impact on one’s overall mental health and sense of self.

I can’t tell you how many times I’ve heard stories from people who breezed through their teenage and young adult lives pimple-free only to meet angry red spots and lumps covering their chins and faces in their thirties and forties. Acne has long been viewed as a rite of passage through adolescence, but it’s not something an adult should be grappling with. What’s going on? A whopping 54 percent of women age twenty-five and over have at least one type of facial acne.³ And other skin disorders are on the rise, including the scariest one of all: skin cancer. In 2017, a report by the Mayo Clinic sent shock waves through the medical community, stating that between 2000 and 2010, squamous cell carcinoma (also called cutaneous squamous cell carcinoma) diagnoses increased 263 percent, while diagnoses of basal cell carcinomas increased 145 percent.⁴ These numbers are mind-boggling given the level of sunscreen use today. To say we’re entering a new era of skin conditions is an understatement. We’re also embarking on new treatment territory, and I’ll be discussing all this in the pages that follow.

Dermatologists only make up 1 percent or less of all doctors, but we prescribe almost 5 percent (if not more) of all antibiotics, which have long been held as the gold standard for treating many skin conditions.⁵ Now, in the wake of rising antibiotic resistance, we are forced to look elsewhere for solutions. Part of my work today involves passionate formal talks to other dermatologists and doctors about this dire matter and pushing for change. I am sounding the alarm. We dermatologists are part of the problem, but we need to be part of the solution. The silver lining of the antibiotic crisis, however, is that it’s opening the door to understanding the power of balanced gut microbes and probiotics in the treatment of skin. As the term suggests, probiotics (meaning “for life”) are beneficial strains of live bacteria that you can ingest through foods, some beverages, and supplements. The science in this area is exploding with new research to show that probiotics can help recolonize the intestinal microbiome and can even help balance certain hormones. We’ll be exploring all these mechanisms, which have everything to do with skin health. The science behind topically applied probiotics is also a burgeoning area of study. We’ll see how your skin’s microbiome has a big say in your skin’s health and function.

Some of the information in this book will serve as a wake-up call you did not expect. Get ready to ditch a few of your trusty daily habits and establish new, unexpected ones. Do you drink milk and diet soda? Time to rethink. Do you go through the same physical exercise routine almost every day? Or barely bust a move at all and have no personal downtime? Time to rethink. Do you use hand sanitizers and antimicrobial soaps, or regularly wash your face with exfoliating scrubs or tools like brushes, loofahs, and abrasive washcloths? Time to reassess. But again, don’t worry about bracing for extreme overnight changes. I promise to make this practical for the real world. Hey, I still love to play outside under the sun and eat pancakes on Sundays. And yes, I have been known to get fully dressed in workout clothes only to climb back into bed with my daughter and wake up an hour later when it’s time to get her dressed for school. I’m not your typical dermatologist, one who preaches staying in the shade. I want my patients and readers to live out loud and feel their most confident every single day. To find that balance we all seek in life. To cherish their health and to make the most of it.

Most dermatologists, for example, will tell rosacea patients to avoid typical triggers. Want to know what those are? Exercise, alcohol, hot beverages, spicy foods, hot temperatures, and very cold temperatures. From my perspective, that’s like asking someone to zap all the joy out of life (and it’s no wonder patients with rosacea have a hard time being compliant with those recommendations). Unrealistic. What kind of life is there without a margarita and Mexican food once in a while? How can I expect someone to start her day without a hot cup of joe? And how could I possibly tell someone not to exercise when we know how much exercise benefits the entire body? Yes, there are certain things that can trigger certain skin problems, but my goal is to find workable, real-life solutions so no one feels deprived.

You will never hear me ask my patients to give up all the things that make life fun and contribute to overall health and well-being for the sake of their skin. Moderation is key. I am all about finding ways to get these skin conditions under control while living life to the fullest and relishing every moment. My message is equally about self-empowerment, self-improvement, and liberation from the clutches of feeling unattractive. I know of no easier or quicker way to get more of what you want out of life than to first love the skin you’re in, as the old Olay commercial advises.

In this book I present a revolutionary new way to think about and take care of your skin. Whether you’re hoping to end a chronic skin condition or enhance your skin’s appearance, you’ll find easy, simple solutions you can implement in your life right away and see results relatively quickly—in as little as three weeks. No surgery or prescriptions are required. (Of course, it’s fine if you are already following a course of treatment recommended by a dermatologist, and it’s fine if you want to visit a dermatologist today and use my program in combination with a formally prescribed regimen. This program is super compatible with prescribed treatments.) Soon you will learn to love your good bugs and let your personal transformation unfold before your eyes.

This isn’t just about skin, either. The strategies in this book will elevate everything about your health. Happy, glowing skin is a reflection of overall general health. And you’ll gain other measurable benefits, such as

In the pages ahead, we’re going to get up close and personal with this remarkable organ called skin. In part I, you’ll learn more about why getting clear, glowing skin is an inside job—from your state of mind and how your gut functions to what you put in your mouth and on your skin. You’ll gain a skin-care education that probably goes against conventional wisdom (be prepared to throw some of your beauty products away). Then, in part II, you’ll learn practical tools that will transform you and your skin. By the time you reach my three-week action plan in part III, you’ll be primed—and excited—to put these ideas into practice. You’ll be making subtle, doable shifts in your daily habits, from what you eat for breakfast to how you exercise, reduce stress, supplement with vitamins and probiotics, ensure restful sleep, and treat your face.

Get ready to go. And get ready to glow.