There are some new advanced heart disease tools…and boy do we need them! There are some heart-health trends that are concerning cardiologists. There is a crisis in terms of a lowered life expectancy for the first time in decades according to cardiologist Sadiya Khan, M.D., assistant professor of medicine and of preventative medicine at the Northwestern University Feinberg School of Medicine in Chicago. The lowered life expectancy is due to several reasons: 1) midlife and younger adults are dying of heart diseases more often- death rates rose 8.5% for adults aged 45-64 between 2010-2020. 2) Fatalities due to heart disease for those over the age of 65 also rose significantly with our older population growing. 3) The COVID pandemic fueled the heart disease resurgence. The side effects of the pandemic’s long-term legacy of weight gain, inactivity and stress raised heart attack deaths by 21% for those 45-64 and 17.9% for people over age 65. The virus itself also plays a direct role in how lingering heart risks have been found a year after COVID infection. COVID could emerge as the #1 risk factor for future heart disease. We know a lot about how our lifestyle habits- diet and exercise-can prevent or increase cardiovascular risk. There are 4 new advanced heart disease tools to know and ask your doctor about.

1. Cleerly- an FDA approved system created by James Min, M.D. for evaluating heart plaque in CCTA (coronary computed tomography angiography) images. The plaque is assigned to a risk stage determining if it is hard stable plaque (good) or soft unstable plaque (not good). Patients can actually view the pictures and see what’s going on inside their own heart. This motivates people to stick with their medications and healthy habits. Cleerly health
2. Intravascular Lithotripsy is a new technique approved by the FDA in 2021 that uses shock waves to break up hard plaque deposits in vessels (similar to what they use to break up kidney stones). Patients can receive a stent after this procedure that are stronger, safer and more flexible. Biodegradable stents are on the horizon.
3. Advanced heart drugs: Sodium glucose transporter 2 (SGLT-2) inhibitors have been on the market to treat diabetes. But they really reduce episodes of heart failure in patients with or without diabetes. Studies have shown it can be used to cut the risk of hospitalization or death from heart failure by 33%. The other drug is PCSK9 for those who cannot tolerate or have not seen enough of a therapeutic effect with statins. It is given by injection q 3 or 6 months and lowers LDL cholesterol by 50-60% and also reduces the odds of a heart attack by 20% more than statins alone.
4. Transcatheter aortic valve replacement (TAVR). Instead of requiring open heart surgery which is deemed too risky for the elderly population (that need it most), the aortic valve can be repaired by implanting a new valve using a catheter that is threaded through the femoral artery. Patients are usually discharged after 1 overnight stay in the hospital.

According to a 2021 report from the American Heart Association, 77.5% of men and 75.4% of women ages 60-79 have some form of cardiovascular disease. Among those of us 80 and older, 90% have it. And by the time women reach their 70’s or 80’s, their risk of heart disease exceeds that of men. I know these statistics sound daunting….but the more we are aware of our own risk factors and have tools to measure our own heart disease, the more we can be proactive in prevention and early treatment.

References: Cleerlyhealth.com

Harrar, S. America’s war against heart disease. AARP Bulletin. Jan/Feb 2023. P 8-16.

Healthy eye sight is dependent upon our overall well-being, which is dependent upon our genetic make-up, the foods we eat, our activity level, work environment and exposure to airborne toxins. Aging macular degeneration (AMD) is one of many eye diseases that can be slowed down. Although we can’t avoid aging or genetics which are the main causes of AMD, we can control other risk factors and delay or slow the progression of the disease.

AMD occurs when there is damage to the part of the retina known as the macula- which is the part of the eye that controls sharp central vision. When the macula deteriorates, it causes blurred vision. It may affect the ability to drive, to see faces and to read smaller print, but it rarely causes blindness. AMD

Specific habits have been identified in studies to be damaging to eye health. The main risk factors besides age and genetics is smoking, high blood pressure and a diet high in saturated fats and refined processed foods. So how can we prevent vision loss and keep our eyes and bodies strong? Here are 6 steps in preventing age-related macular degeneration:

1. Stop Smoking! Studies have shown that smokers have a 2-3 times higher risk in the development of AMD than non-smokers. A 2015 study found damage and inflammation to several layers of the macula in smokers. Smoking causes high blood pressure which raises pressure in the blood vessels and raises oxidative stress and free radicals.

2. Eat more leafy greens which are rich in carotenoids that your eyes need, especially lutein and zeaxanthin. These particular carotenoids have been shown to be low in people with macular degeneration. Collards, kale and spinach can be added to soups, salads, or pureeing them in smoothies. These nutrients in foods or supplements have been found to prevent and even improve AMD in many cases. Vitamin C can enhance the absorption of lutein.

3. Weight loss (if needed) helps digestion and lowers inflammation which allows for a healthier microbiome. Avoid the typical Western Diet which is high in saturated fats and high fructose corn syrups, sugars and processed foods.

4. Choose healthy fats such as omega-3 fatty acids. Omega-3’s have the ability to regulate formation of extraneous blood vessels that distort vision. Eating fish is a great way to increase omega-3 in your diet. Some people need supplementation and 2 grams daily with food is a good starting place. Vegetarians can choose algae, hemp or krill as good sources.

5. Zinc is necessary for a healthy macula and is found abundant in meats and seafood. It is also in nuts, grains and legumes but is not in a readily absorbable form. Zinc supplementation may be needed for vegetarians and vegans. A RBC Zinc level can determine deficiencies.

6. Vitamin D3 is easy to measure in a blood test. Low levels are associated with increases in macular degeneration symptoms. Vitamin D has anti-inflammatory and anti-angiogenic benefits, especially where genetic risk is greatest. D3 has an important role in the immune system and aging process of AMD and all diseases.

Choose a positive, healthy lifestyle that includes exercise, daily meditations or walks in nature and a healthy diet. It may prevent or slow down the diseases of aging and improve the quality of your life.

References: Grossman, M. Eye disease, integrative vision care, and nutrition. Townsend Letter. April 2022, issue #465, p 42-43.

Age-related Macular Degeneration. https://www.hopkinsmedicine.org/health/conditions-and-diseases/agerelated-macular-degeneration-amd.

Here’s to a year of hope. We have slowly come out of this pandemic a little dazed and confused but for most of us all the better and knowledgeable about how precious life is. There were astounding new technologies and medical breakthroughs in 2022. Here is Wellcast’s top 10 Health Breakthroughs:

10. “Smart stethoscopes” are stethoscopes that identify heart murmurs before they can be heard. It can detect the slightest of murmurs which is important since 5-10% of people have one form of valvular heart disease or atrial fibrillation.

9. Hearing Aids: Over-the-counter (OTC) versions have arrived. Close to 90% of people with hearing loss have mild to moderate losses which these OTC versions would help. It is best to get a hearing test first. Learn more at aarp.org/hearing.

8. Eye Implants: For those who have age-related macular degeneration (AMD), the leading cause of severe vision loss in those over age 50, you can now opt for an eye implant device instead of monthly eye injections. This is primarily for the more severe type (“wet AMD”).  The implant releases a steady dose of a drug, ranibizumab, to control blood vessel growth.

7. Ceramic teeth: Titanium implants have been the gold standard for dental implants. Ceramic options are worth mentioning because it is an option that is good for people with metal hypersensitivities and it is healthier for your gums. It also doesn’t show gray metal through the gum tissue.

6. Focused Ultrasound for Parkinson’s Patients: Like a magnifying glass concentrating sunlight… focused ultrasound beams of sound waves pinpoints an area deep in the brain, heating up and destroying cells associated with the movement problems of both Parkinson’s disease and essential tremor.  This FDA-approved procedure has helped calm shaking, stiffness and other movement problems that are due to these nervous system disorders.

5. Blood Test that detects early cancers called the Galleri, multi-cancer early detection (MCED) from the health company Grail screens for more than 50 different cancers. It searches a blood sample for tiny scraps of DNA released by cancer cells. There are some questions about false positive test results which could lead to expensive, invasive and anxiety-provoking procedures and treatments. But then, the earlier a cancer is found the better the outcome. Follow-up studies are currently being done.

4. A new drug to treat Lp (a): Lipoprotein (a) is an independent risk factor for atherosclerotic heart disease. A new drug, Olpasiran is a small RNA molecule that interferes with the synthesis of Lp(a) in the liver. This is a major breakthrough because it is so difficult to treat Lp(a) outside of using oral Niacin (which commonly causes flushing so many people cannot tolerate it) and injectable drugs known as PCSK9 inhibitors (ie Repatha) given every 2 weeks.  Olpasiran is a subcutaneous injection given every 12 or 24 weeks. More studies are being done before it comes out to market.

3. Inhaler Sensors that monitor your meds are now available. Nearly 1/3 of older adults miss doses on their inhaler schedule, and 74% use their inhalers improperly. Propeller Health’s FDA-approved sensors use a smartphone app linked to the senses to keep track of your inhaled medications.                                         For more information go to inhaler sensors

2. Next generation of mRNA vaccinology: An effective COVID-19 vaccine was developed, produced, approved and delivered in less than a year!! New mRNA vaccines are being developed to prevent cancers, Zika virus and others. The world needed a new vaccine technology and what better way than a pandemic to get things started.

1. Paxlovid (nirmatrelvir-ritonavir): an oral pill for the treatment of mild-moderate COVID-19. Prior treatments were intravenous medications at hospitals and certain service centers. This pill that could be easily prescribed reduced hospitalization from 50-80%. A real deal breaker in getting people better and avoiding severe complications and disease progression.

Wishing you a very healthy, peaceful and hopeful New Year!

References: Harrar, S. Medical breakthroughs that are changing lives now. AARP. Oct/Nov 2022, p. 51-59.

Reale-Cooney, A. Cleveland clinic unveils top 10 medical innovations for 2022. Cleveland Clinic Newsroom. Feb 16, 2022.

Lin, P. Paxlovid use is associated with decreased hospitalization rates among adults with COVID-19. Practice Update, The New England Journal of Medicine, Dec 20, 2022.

Ostrominski, J. Efficacy and safety of Olpasiran for Lp(a0 level reduction. Practice Update, The New England Journal of Medicine, Dec 18, 2022.

Urinary tract infections (UTI) are among the most prevalent bacterial infections in both inpatient and outpatient facilities. They affect about 150 million people annually. About 1 in 7 women suffers at least one infection per year. About a third of those women develop another UTI 6-12  months after the first infection.  There are many ways to prevent recurring urinary tract infections. The prevalence of bacteriuria (a common  feature in UTI) for those over the age of 60 is significantly higher in women than men. Nearly 20-30% of women with an infection experience recurrence. High risk populations for UTI include pregnancy, elderly, children, people with an indwelling catheter and those with a neurogenic bladder. Frequent sexual intercourse increases recurrence rate of UTI’s. Abstinence when having an infection will improve recovery and urinating immediately after coitus is recommended along with the higher intake of water.

A recurrent UTI is classified as having 2 symptomatic episodes within the last 6 months or if 3 episodes have occurred within the last 12 months. There are many approaches to reducing the recurrence rate of urinary tract infections. Non-antibiotic choices are best because they are easily managed but also because it prevents the development of resistance and the corresponding adverse reactions of antibiotics. Here are 6 ways to prevent urinary tract infections:

1. Drink sufficient fluids: The rule of thumb is to drink 1/2 your body weight in ounces. So if you weight 140 pounds, then you should drink about 70 ounces of water per day. Of course certain diuretics such as caffeine and alcohol, require adjustment of those numbers as well as exercise so that may mean close to 85 ounces/day. If you are prone to re-infection, caffeine and alcohol should be limited since they can irritate the bladder wall and cause dehydration.
2. Cranberries (Vaccinium macrocarpon): originated in New Zealand and is loaded with phytochemical compounds such as proanthocyanidins (PACs), anthocyanin, benzoic acid and ursolic acid. Escherichia coli (E.coli is a primary pathogen in UTI’s) is prevented from adhering from the uroepithelial cells by PACs contained in cranberries in the urinary tract. Even though studies on long-term prevention using cranberry products have been inconsistent, I still recommend them since they are safe (especially in children), easy to use in an extract capsule form or drink, and clinically effective in many of my patients.
3. D-mannose: This is a simple sugar, or monosaccharide  found in many fruits. Small clinical studies suggest that oral D-mannose may reduce UTI recurrence,  when used alone or when in combination with other ingredients (cranberry extract, tara gum and probiotic bacteria 1-2.5 billion live cells of L. planetarum, L paracasei and Strep thermophilus). It also inhibits E. Coli bacteria from binding to the bladder wall. In one study, the intake of 2 gms of D-mannose dissolved in a glass of water every day showed a significant drop of urinary tract infections compared with placebo.
4. Uro-Vaxom is an immune-stumulant agent with bacterial cell wall components from the strains of E.Coli. Uro-Vaxom caps. In 2 meta studies, the recurrence rate was reduced by 39% compared to placebo. There was a significant reduction from treatment time to breakthrough infections. Uro-Vaxom trial
5. Estradiol or Estriol vaginal cream for postmenopausal women. This treatment serves as therapy for vaginal atrophy and reduces both colonization with uropathogens and also balances the vaginal PH to reduce risk of vaginal bacterial infections.
6. Antibiotic therapy should only be used when all other options have failed. When choosing an antibiotic, make sure a urine culture has been done to choose the right antibiotic and avoid resistance. Single dose postcoital antibiotic prevention is a good prevention especially for women in whom a correlation between recurrent UTI’s and sexual intercourse has been suspected.

References: Hertlein, A. Recurrent Urinary Tract Infections: What’s Good Prophylaxis? Medscape, Oct 31, 2022.

Magasi, P, et al. Uro-Vaxom and the management of recurrent urinary tract infection in adults: a randomized multi center double-blind trial. Euro Urol, pubmed.ncbi.nim.nih.gov. 1994

Hisano, M, Bruschini, H et al. Cranberries and lower urinary tract infection prevention. Sao paulo clinic. 2012 Jun 67 (6): 661-667

Why is it that some people have a normal sense of thirst and drink enough water throughout the day and others don’t have the urge to drink at all?

And more importantly…why don’t the elderly feel thirsty?

So what actually allows us to feel thirsty? It comes from either a low volume of fluids in the body or a higher concentration of certain osmolites, such as sodium. Certain receptors (osmoreceptors) situated in the brain are stimulated by an increase in plasma concentration and causes us to fell thirsty. When the body loses water, it is depleted from both the extracellular and intracellular compartments, but it may not be lost equally from each of those spaces. Regardless of whether the depletion is from the intra- or extracellular compartment, our bodies have a range of compensitory mechanisms that respond. These responses involve certain hormones (Vasopressin), stimulation of certain systems in the kidney to conserve water and sympathetic activation that minimizes changes in body fluid volume and composition mechanism of thirst . These mechanisms are amazing, but they don’t restore body fluids to their original state. For that to happen we have to drink! So when the elderly don’t feel thirsty, it’s important to find ways to help them drink.

Thirst is not always a reliable indicator of dehydration or the bodies need for water. Many people, especially the elderly don’t feel thirsty until they’re already dehydrated. There are many causes for lack of thirst sensation:

1. As we age, the amount of fluid volume in our body decreases.
2. The thirst response in older people becomes weaker, so they may not know they need to drink.
3. The elderly have a decrease in kidney function plus they may be on mediations that lead to more fluid loss, such as diuretics. Dehydration can lead to constipation, electrolyte imbalance, kidney problems, headaches and loss of balance.

Other causes for lack of thirst could be that you are dehydrated and just don’t feel thirsty as dehydration progresses. Your body fails to send signals to your throat and mouth to tell you to drink. Certain illnesses can also reduce the thirst reflex. Diabetes, physical exhaustion and mental disorders are a few examples.

We may also forget to drink due to being too busy, stressed and not paying attention. We know that stress, which stimulates adrenaline (in addition to too much coffee!) can decrease our appetite and sensation of thirst. It can become a bad habit and our bodies can sometimes adapt to this habit.

But the importance of hydration cannot be understated. We need adequate fluids to flush toxins, reduce muscle cramps and headaches, help our mood and energy, think clearly, have healthy skin and hair and improve sleep. Sometimes we can be dehydrated and have nausea so we don’t want to drink or eat and can feel agitated, moody, lethargic and confused.

Needless to say…let’s be more conscious of our drinking habits and stay hydrated.

Suggestions: Drink electrolyte fluids such as sports drinks or electrolyte powders that you put in water. Sparkling water, low sugar fruit juices are helpful if you don’t like the taste of water or mixing water with fruit juice. Reduce tea, coffee and alcohol as they have a diuretic effect. Take small sips instead of large amounts of water all at once.

References: www.next-health.com, news. March 17, 2022. Next Health Staff.

Clevelandclinic.org. Health Essentials. Drink Up: Dehydration is an often overlooked Health Risk for Seniors. Nov 29, 2018.

Ahhh..sugar, how sweet it is. Sugar is the most over-consumed carbohydrate in the world. We can’t live without it, because it has benefits like fueling our body and especially our brain but too much of it can cause multiple heath problems. So how does it all work? We process carbohydrates from the food we eat, such as fruits, vege’s. fiber and dairy products, and turn much of it into glucose. The problem occurs when we eat more foods with added sugar ( donuts, bread, candy soda, sweet fruit punch, etc), vs foods with naturally occurring sugar. The problems and disadvantages with overconsumption of sugars cannot be understated. Risks include metabolic syndrome, high cholesterol, heart disease, fatty liver disease, weight gain, dental cavities, insulin resistance and type 2 diabetes. Plus sugar can make you feel tired, cause headaches and difficulty concentrating after that quick surge of energy has fallen. So are artificial sweeteners the answer?

Certain sweeteners such as fruit juices, molasses, honey and maple syrup contain natural sugars and have some nutritional benefits. Fruits have fiber, vitamins and antioxidants, while honey and maple syrup have antioxidants and minerals such as iron, zinc, potassium and calcium.

In an effort to reduce the long-term manifestations of sugar, many people have resorted to sugar substitutes. The goal is to lower the risk of adverse health conditions but still taste that sweetness in our foods. It may seem like the best of both worlds but it actually is worse for you.

A prospective cohort study was done to study the associations between artificial sweeteners from all dietary sources such as sugar drinks, table top sweeteners and dietary products overall and also by certain molecules (aspartame, sucralose, acesulfame potassium) of artificial sweeteners and the risk of cardiovascular disease. A cohort study is a longitudinal study that follows over time a group of similar individuals who differ with respect to certain factors under study to see how these factors affect certain outcomes.

This study included over 103,000 mainly French females that were followed for an average of 9 years. A food questionnaire used 24-hour recalls which recorded what everyone ate or drank for multiple 24-hour periods. The study included all food sources of artificial sweeteners. The endpoints included all cardiovascular disease including heart disease, coronary heart disease and stroke.

The findings suggest a potential direct association between higher artificial sweetener consumption and increased cardiovascular disease risk. This study also broke down which artificial sweeteners had the greatest risk of disease. Aspartame (Equal) was associated with the greatest risk of stroke. This sweetener was found to be metabolized into many compounds, including formaldehyde. This can break down the blood-brain barrier causing risk of CNS toxicity, inflammation and stroke. BMJ Artificial Sweeteners

The other common artificial sweetener was Sucralose (Splenda). This was associated with the highest coronary heart disease risk. It is only partially absorbed chemically and has the largest effect on the microbiome. Avoid Artificial Sweeteners.

There are many harmful effects of artificial sweeteners including weight gain (the main reason people use these products!), metabolic dysregulation, inflammation, dysbiosis and endothelial dysfunction. These substances are often used in combination with other unhealthy lifestyle choices. These substances are being used more and more in our food supply especially for low calorie, low cost processed foods.

There are safer choices that I recommend:

1. Satisfy sweet cravings with fruit such as berries, bananas and mango. Try dehydrated fruits that you can chew on that gives a certain texture that may satisfy you. Skip the sodas, energy drinks and fruit juices.

2. If you must have a sweetener then consider a novel sweetener that’s derived from plants like, Stevia or Monk fruit. Yes, there are other sweeteners that come from plants, but novel sweeteners don’t lead to weight gain or blood sugar spikes and they are less processed.

3. And please…do not use Agave. It is worse than high fructose corn syrup because it is higher in fructose.

4. I would also consider a good local source of honey. It is 25% sweeter than table sugar so you need very little to get that sweet taste.

References: Rakel, D. Association intakes of artificial sweeteners with risk of cardiovascular diseases. BMJ, Practice Update. Sept 22 2022.

Leonard, J. Is honey better for you than sugar? Medical News Today. June 1, 2017.

Ziesel, J. Facts about sugar and sugar substitutes. Johns Hopkins Medicine- Health

For many years now the primary treatment for acne has been over the counter creams and cleansers such as benzoyl peroxide/salicylic acid, Vitamin A derivatives such as Tretinoin (Retin-A), antibacterial soaps, and of course oral antibiotics.  These treatments are still being used today. But now there is new evidence in the literature on the pathophysiology of acne development. This has lead to newer natural acne treatments. We have known that acne patients and healthy controls have different compositions of skin and gut microbiota. Now we see how acne treatment can disrupt the microbiome, especially with the use of oral antibiotics. This can lead to gut dysbiosis which can lead to chronic inflammation, obesity, cancer, cardiovascular disease, neuropsychiatric conditions such as dementia, depression and anxiety. This gut dysbiosis plays an important role in inflammatory skin conditions such as acne.

One way to look at this gut imbalance is to do a stool analysis. I look for nutritional deficiencies and get labwork that includes nutrient levels, inflammatory markers, blood sugars and food allergy tests.  Some patients may have adequate amounts of zinc and omega 3 fatty acids, but many do not. Studies have found significantly lower serum zinc levels in patients with severe acne than in controls. Acne has an inflammatory component, and lower serum zinc concentrations may reflect a response to inflammation rather than a true zinc deficiency. Pantothenic acid (B5), L-carnitine and oral probiotics have also been helpful. For women, Vitamin B6 (Pyridoxine) at 50 mg/day starting 1 week prior to menses and continuing throughout menstruation showed a 72% decease of premenstrual acne flairs.

There are also topical probiotics that can be used to treat acne that use AOB (ammonia-oxidizing bacteria) as the key ingredient which is a type of bacteria already found on the skin. Our natural skin bacteria gets damaged and depleted over time due to harsh soaps and cleansers which many people use to treat acne. This live bacteria (topical probiotic) replenishes what the skin is missing with minimal side effects Mother Dirt. This is a very natural acne treatment.

For female hormonal acne and especially women who have polycystic ovarian syndrome (PCOS), I recommended D-chiro-inositol which is an isoform of inositol that reduces hyperandrogenism better than myo-inositol. D-chiro-inositol helps regulate cycles while reducing symptoms of acne and hirsutism.

Diet is extremely important when it comes to acne. I discuss when and what people eat and drink and then review their stool test results to allow a more complete understanding of what factors shape the microbiome. Common deficiencies I see in the gut is low fiber, low bacterial (probiotics), low stomach acids and low pancreatic enzymes. Acne has been associated with a diet high in refined sugar and fatty foods including processed foods and alcohol. Exacerbations of acne can result from allergic food reactions or from the effects of biologically active substances in certain foods, such as hormones in cow’s milk or amines and other chemicals in chocolate. Eating whole foods is best, in which there are no labels or ingredient lists on products such as fruits, vegetables, lean proteins, and healthy fats such as avocado, olive oils, fish and nuts/seeds. The gut is an important ecosystem that can cause non-GI symptoms such as acne, eczema, fatigue and nutrient deficiencies.

Last but certainly not least is thyroid. The thyroid gland is the “control tower” of your endocrine system. It secretes hormones into the circulatory system that regulates and controls metabolism. The endocrine system is responsible for growth, repair, metabolism (the rate at which food is burned for energy), energy and reproduction. If that system is out of balance, it can significantly effect your health. When thyroid hormone is deficient (known as hypothyroidism) the body cannot convert cholesterol to other steroids such as Pregnenolone, Progesterone and DHEA. Of all of these…Progesterone is the most important when it comes to acne.

Women have thyroid receptors on their ovaries. So if there is an underachieve thyroid, women will not ovulate as effectively and as a result will not produce adequate amounts of progesterone. This may be why many women suffer from premenstrual acne among other symptoms such as anxiety, irritability, breast tenderness or headaches. Yes, all a result of low progesterone and possibly due to a hypothyroid condition. Low thyroid function increases inflammation because it regulates skin function and how much oxygen the skin absorbs. Thyroid levels can be checked with a simple blood test. Talk to your practitioner to get tested.

Acne can be treated in a ‘wholistic” and integrative way vs mainstream pharmaceutical methods. Treatment can also give you additional benefits that you can see and feel besides clear skin.

References: InYoung, K. Recent updates in pathophysiology and treatments in adult acne. Dermatology, Primary Care, May 25, 2022. Elsevier Inc.

Gaby, A. Acne Vulgaris. Nutritional Medicine, Second edition, 2017. Fritz Perlberg Publishing, Concord NH. pp 707-210.

Villett, M. Is low thyroid causing your “hormonal” acne? The Skincare Edit. 2019.

Amer M. Bahgat MR, Tosson Z, et al. Serum zinc in acne vulgaris. IntJ Dermatol 1982; 21: 481-484.

Snider B, Dieteman DF. Pyridoxine therapy for premenstrual acne flair. Arch Dermatol 1974; 110:130-131.