Introduction
Our last post addressed the topic of why lichen sclerosus (LS) is commonly misdiagnosed as a yeast infection. This included general information about yeast infections, including what they are, risk factors, signs and symptoms, diagnosis, and treatment. Today’s post will dive deeper into lichen sclerosus and yeast infections. Particularly, we will address questions we frequently get asked from the LS community. These questions include “Do steroids cause yeast infections for people with LS?” and “What are my options if I experience recurrent, stubborn yeast with LS?”
Disclaimers
*This post is evidence-based; I draw on the medical literature to share what you need to know about lichen sclerosus as well as candidiasis (yeast infections). Importantly, what I share is my interpretation of the science and data.
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Do Steroids Cause Yeast Infections in People with Lichen Sclerosus?
Lichen sclerosus is a chronic, inflammatory skin condition considered autoimmune by most of the medical community. It causes symptoms like vulvar burning, itch, pain, and pain with sex. The gold standard and first-line treatment is ultrapotent topical corticosteroids.
Lichen Sclerosus Treatment
Why are topical corticosteroids (steroids for short) first-line treatment? In large part, it is because of all the treatment options, steroids have the most research behind them, supporting both their efficacy (their ability to help manage the condition) and safety. Further, steroids have shown to significantly reduce the inflammation caused by LS in several studies (Ching-Chi et al., 2012; Corazza et al., 2021; De Luca et al., 2023; Goldstein et al., 2011; Kirtschig, 2016; Krapf et al., 2020; Lee and Fischer, 2018) Finally, there is good evidence suggestion the proper and consistent use of steroids can reduce the risk of developing vulvar cancer (Lee, Bradford, and Fischer, 2015).
Steroid Side Effects: Do Steroids Cause Yeast Infections?
One thing I stress often is the fact that all medications and procedures come with benefits and risks. Ideally, you want the overall benefits to outweigh the risks. Risks include things like side effects.
Many people worry about the side effects of steroids. For a general overview of steroid side effects, click here to learn more. For the sake of this post, we will focus on yeast infections.
So, do steroids cause yeast infections?
The answer is not necessarily, but they can for some people. First, let’s look at what some of the research says on the topic.
What Does the Science Say?
Before we start, a quick note about the research. Unfortunately, there are not many studies that look at steroids and yeast infections. That said, I will share the few that touch on the topic.
One study examined the efficacy of Clobetasol use in children with vulvar lichen scleorsus. The study included 15 children. Of this group, 1 child developed a vulvar yeast infection due to Clobetasol use (Smith and Quint, 2001).
Another study analyzing the efficacy of Clobetasol, including 83 people with vulvar lichen sclerosus, found that of the group, only 1 patient out of 83 developed a yeast infection from Clobetasol (Renaud-Vilmer et al., 2004).
Finally, a paper by Lee and Fischer (2018) noted that steroid therapy can sometimes cause yeast infections as a side effect.
Thus, it seems that yeast infections can be a side effect in a small subset of folks with vulvar lichen sclerosus. Why exactly this is, and who is more likely to experience this side effect, is unclear; we need more research on this aspect.
Recurrent, Resistant, and Complicated Yeast Infections
One-off yeast infections can happen to anyone. However, sometimes, yeast infections are more complicated. They may be resistant or recurrent yeast infections, which can be more frustrating to deal with.
Resistant Yeast Infections
A resistant yeast infection occurs when the yeast develops a genetic mutation where the infection either partially responds or does not respond at all to standard treatment (Goldstein, Pukall, Goldstein, and Krapf, 2023). For example, about 2-7% of yeast infections are shown to be resistant to fluconazole (ibid). Therefore, if you were diagnosed with a yeast infection, prescribed typical yeast infection treatment, and do not respond, we recommend asking your doctor for a yeast culture to identify the specific strain of yeast. Certain strains of yeast require different treatment plans. For example, candida glabrata may need a new oral medication called ibrexafungerp (Brexafemme), boric acid suppositories, or flucytosine cream (ibid).
Recurrent Yeast Infections
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If the yeast strain is not resistant, but you keep getting chronic yeast infections, you may be dealing with recurrent yeast. Recurrent yeast is defined as having four or more yeast infections in a year (Vieira-Baptista and Borstein, 2019). Recurrent yeast can be caused by internal or external collection/backup of yeast, diabetes, and IUDs.
Let’s start with internal collections of yeast. Essentially, this means that an excessive amount of yeast has accumulated in the body. A common area is the rectum, as the gastrointestinal tract can be a hot spot for yeast accumulation-especially in people who eat a high-sugar diet or have taken antibiotics. In these cases, Goldstein et al., 2023 recommend nystatin, which stays in the gastrointestinal tract and helps clear out the excess of yeast.
An external buildup of yeast can be from clothing and towels that have not been properly washed with enough hot water to kill the yeast. Changing your washing machine or hand washing in hot water may help (ibid).
Goldstein et al., 2023 recommend that people with recurrent yeast be checked for diabetes, as uncontrolled diabetes can cause recurrent yeast (Goldstein, Pukall, Goldstein, and Krapf, 2023). The authors also note people with IUDs (aka an intrauterine device to help prevent pregnancy) are more at risk for recurrent yeast. Therefore, if you have an IUD, they recommend discussing prophylactic therapy and weekly doses of oral antifungals (ibid).
What to Do if You Suspect Your Steroid is Causing Yeast Infections
First and foremost, if you suspect your steroid is causing chronic yeast infections, you’ll want to make an appointment and discuss this with your healthcare provider.
Important questions to ask your healthcare provider at your appointment include:
- Do you think steroids are causing my yeast infections?
- If yes, ask them to explore some of the options below, such as reducing the potency of your steroid or compounding an antifungal into the steroid.
- How should I treat my LS while I have a yeast infection? Do I continue using my steroids on my normal dosing schedule, or do I need to make modifications?
- If they want you to make any modifications, be sure to ask them to note all the changes they want you to make and for how long.
- Ask if it’s possible that you have either resistant or recurrent yeast and if they can explore appropriate testing.
- For example, if you have recurrent yeast, you may want to ask them to check for diabetes, especially if you change your steroid or add an anti-fungal and still see no relief from recurrent yeast.
In the meantime, while you wait for your appointment, you may want to wear plain, white cotton underwear, keep the area dry and clean, and avoid fragranced soap products (wash with warm water and your fingertips).
How to Manage Chronic Yeast Infections from Lichen Sclerosus
If your doctor suspects steroids are the cause of the chronic infections, they may suggest some of the following options:
- Reducing the potency of your steroid. Steroids come in different categories based on how strong they are. You may need to drop from an ultrapotent to a potent or mid-potent steroid.
- Prescribing a preventative, monthly, oral anti-fungal medication.
- Prescribing a compounded medication that mixes your steroid with an antifungal.
- Reducing how frequently you treat. For example, if you treat every other day, they may recommend 1-2x per week.
- Prescribing another medication such as calcineurin inhibitors (e.g., Tacrolimus or Pimecrolimus).
(Lee and Fischer, 2018)
If your doctor thinks the issue is not steroids but resistant or recurrent yeast infections, they will want to:
- Perform a yeast culture to determine the strain of yeast to see if it’s a resistant strain.
- Different strains may require different medications and boric acid suppositories instead.
- Prescribe oral nystatin if they believe there is recurrent yeast infections due to a backlogged collection of yeast in the GI tract.
- Discuss lifestyle changes such as clothing.
- Discuss prophylactic therapy and weekly doses of oral antifungals if you have an IUD.
(Goldstein, Pukall, Goldstein, and Krapf, 2023).
Importantly, you may need to seek out a vulvar specialist or a doctor with a special interest in vulvovaginal health to support this part of your health journey.
What’s important to note is that you have options that still include treating your LS. You may have to play around with dosing or medications, but ideally, you will find something that allows you to treat your body without experiencing chronic yeast infections.
Conclusion on Do Steroids Cause Yeast Infections in People with Lichen Sclerosus
In sum, if you suspect steroids are causing your yeast infections, discuss your concerns with your healthcare provider. Some individuals are more susceptible to yeast infections with steroid use. If this is you, many options exist to help reduce yeast infection frequency while treating your lichen sclerosus. It is also important to know that there are more complicated yeast infections, such as resistant and recurrent yeast. Be sure to discuss this with your healthcare provider, and, if necessary, see a vulvar specialist or a doctor with a special interest in vulvovaginal health.
Let us know in the comments if you’ve experienced chronic yeast with LS and how you manage it.
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References
1.Lee A, Fischer G. Diagnosis and Treatment of Vulvar Lichen Sclerosus: An Update for Dermatologists. American Journal of Clinical Dermatology. 2018;19(5):695-706. doi:https://doi.org/10.1007/s40257-018-0364-7
2.Lee A, Bradford J, Fischer G. Long-term Management of Adult Vulvar Lichen Sclerosus. JAMA Dermatology. 2015;151(10):1061. doi:https://doi.org/10.1001/jamadermatol.2015.0643
3.Corazza M, Schettini N, Zedde P, Borghi A. Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects. Biomedicines. 2021;9(8):950. doi:https://doi.org/10.3390/biomedicines9080950
4.Chi CC, Kirtschig G, Baldo M, Lewis F, Wang SH, Wojnarowska F. Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus. Journal of the American Academy of Dermatology. 2012;67(2):305-312. doi:https://doi.org/10.1016/j.jaad.2012.02.044
5.Goldstein AT, Creasey A, Pfau R, Phillips D, Burrows LJ. A double-blind, randomized controlled trial of clobetasol versus pimecrolimus in patients with vulvar lichen sclerosus. Journal of the American Academy of Dermatology. 2011;64(6):e99-e104. doi:https://doi.org/10.1016/j.jaad.2010.06.011
6.Kirtschig G. Lichen Sclerosus—Presentation, Diagnosis and Management. Deutsches Aerzteblatt Online. Published online May 13, 2016. doi:https://doi.org/10.3238/arztebl.2016.0337
7.Smith Y, Quint E. Clobetasol propionate in the treatment of premenarchal vulvar lichen sclerosus. Obstetrics & Gynecology. 2001;98(4):588-591. doi:https://doi.org/10.1016/s0029-7844(01)01496-x
8.Renaud-Vilmer C, Cavelier-Balloy B, Porcher R, Dubertret L. Vulvar Lichen Sclerosus. Archives of Dermatology. 2004;140(6). doi:https://doi.org/10.1001/archderm.140.6.709
9. Goldstein A, Pukall C, Goldstein I, Dr. Jill Krapf. When Sex Hurts. Hachette Go; 2023.
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