Introduction

Welcome to our comprehensive blog on understanding yeast infections, their causes, symptoms, and how they relate to conditions like vulvar lichen sclerosus (VLS) and steroid use. Yeast infections, also known as candidiasis, are a common yet often misunderstood condition that can affect various parts of the body, including the vagina, mouth, and vulva. Whether you’re dealing with a one-off infection or recurrent episodes, it’s essential to understand the underlying causes and effective management strategies. In this blog post, we’ll delve into the science behind yeast infections, explore the potential side effects of steroid treatments, and provide practical advice for managing recurrent infections. Let’s get started!

Disclaimers

*This post is evidence-based; I draw on the medical literature to share what you need to know about vulvar lichen sclerosus and vulvovaginal yeast. Importantly, what I share is my interpretation of the science and data. This post is up-to-date as of the day of publication.

**Dr. Babb and Dr. Foster have reviewed this blog for scientific accuracy. They have also shared some of their thoughts throughout.

***If this post is helpful to you, we’d love your support so we can continue providing important education like this. Make a donation today, volunteer with us, or share our posts in your support groups.

First Things First, What is Yeast?

Yeast is a type of fungus that naturally resides on your skin and in your digestive tract. Having a certain amount of yeast in these areas is perfectly normal. However, when yeast grows excessively, it can lead to a yeast infection known as candidiasis. This common condition can affect various parts of the body, including the vagina, mouth, and vulva.

What Causes Yeast Infections?

Yeast infections can occur due to several factors. Damaged skin or a weakened immune system can create an environment where yeast thrives (Madnani, 2023). Yeast tends to overgrow in warm, damp, and humid conditions, making certain body areas more susceptible to infection, especially within skin folds (ibid). Endocrine disorders such as hypothyroidism, Cushing’s disease, Addison’s Disease, and diabetes may predispose folks to developing yeast infections (ibid). In diabetes, a higher blood sugar level (hemoglobin A1C) leads to more yeast infections. 

Pregnant folks, those who use birth control pills, or folks using estrogen therapy may also be contributing factors (Goldstein, Pukall, Goldstein, Krapf, 2023).

Interestingly, taking antibiotics has also been linked to yeast overgrowth. Antibiotics can disrupt your body’s natural balance of bacteria, allowing yeast to multiply unchecked (ibid). In fact, whenever I used to fill a prescription for antibiotics, my pharmacist would automatically provide me with an oral yeast infection treatment, just in case.

Types of Yeast Infections

While the Candida Albicans fungus causes most yeast infections (ibid), other less popular varieties are C. tropicalis, C. krusei, C. parapsilosis, C.pseudotropicalis, and C. glabrata (ibid). Previously, C glabrata was considered a normal, non-pathogenic or “commensal” organism, but the rise of C. glabrata isolated from symptomatic patients using immunosuppressive medications has led to concern (Fidel et al., 1999).  According to Goldstein, Pukall, and Goldstein (2011), infections caused by Candida Glabrata are on the rise.

Signs & Symptoms of a Vulvovaginal Yeast Infection

Vulvovaginal yeast infections may have some of the following signs and symptoms:

• Itching
• Burning
• Pain with sexual activity
• Fissures on the vulvar skin
• Pain and stinging with urinating
• Vaginal irritation
• Vaginal discharge (often white and thick)
• A rash of small dots or bumps on the skin (called satellite lesions)
• Swelling of the vulvar skin

(Madnani, 2023; Goldstein, Pukall, Godstein & Krapf, 2023)

Important Caveat Re: Vulvar Yeast

It’s important to note that vulvar yeast can present with the signs and symptoms mentioned above but will not have the discharge component. It may look like the skin is red, raw, and inflamed – like a baby diaper rash.

How is to Know if It’s VLS or Yeast – Best Practice for Diagnosis

When reading the signs and symptoms of vulvovaginal yeast infections, you may be thinking, “Well, geez, that sounds an awful lot like VLS.” And you are right. There are many overlapping symptoms and signs, making it challenging to know what is going on. One helpful distinction can be where the symptoms are located: on the skin of the vulva or inside the vagina – if in the vagina, it is likely to be yeast or something else, and not VLS.

Ideally, your doctor would confirm by swabbing the discharge/secretions from the vulva and vagina and examining it under a microscope as well as measuring the PH of the vagina (Goldstein, Pukall, Goldstein, Krapf, 2023). When you are at the doctor’s office, be sure to request they swab the vulvar/perianal areas as well, as a proper diagnosis could be missed if they only swab the vagina.

There is a possibility of a false negative with this kind of testing (Lowe et al., 2009). If you suspect a yeast infection despite a negative result, ask your doctor for a fungal culture to confirm. Dr. Babb notes – Be aware that fungal cultures may take multiple weeks to result.  

Important Notes on Yeast Infection Diagnosis

We appreciate that getting into a doctor (and one that can adequately test) is not accessible to all folks due to financial position, geographical location, etc.

You may try talking to your local pharmacist instead for guidance and recommendations.

Do Steroids Cause Yeast Infections

Most vulvar specialists do not report increased occurrence of yeast infections in their patients who use topical steroids (although it can occur in some). Oral steroids are known to increase the risk of yeast infection, especially in the susceptible groups mentioned above. 

I must admit, there aren’t many studies specifically looking at the connection between steroid use and yeast infections. However, I found some interesting insights from a few studies worth sharing.

2001 Study by Smith and Quint

In 2001, Smith and Quint conducted a study to investigate the efficacy of Clobetasol in children with vulvar lichen sclerosus. Their trial included 15 children, and out of these, one child developed a vulvar yeast infection due to the use of Clobetasol.

2004 Study by Renaud-Vilmer et al.

A 2004 paper by Renaud-Vilmer et al. analyzed the efficacy of Clobetasol for achieving remission and reducing the risk of vulvar cancer. This prospective study, which was conducted between 1981 and 2001, included 83 people with vulvar lichen sclerosus. When assessing the adverse effects of Clobetasol, only one patient out of 83 developed a yeast infection from the medication.

2018 Review by Lee and Fischer

In a 2018 review paper, Lee and Fischer noted that steroid therapy can, in some cases, cause yeast infections. They mentioned that this is commonly controlled with antifungal therapy such as oral or topical nystatin. According to Dr. Foster (Dermatologist and LSSN’s member of the Medical Advisory Board), this is rarely seen in patients with VLS, likely due to the overactive immune system monitoring the skin of the vulva.

What Does This Mean?

It seems that in a small subset of people with vulvar lichen sclerosus, yeast infections can be a side effect of steroid use. This can increase if they are using certain medications or have other conditions such as diabetes. Of course, more research is needed to fully understand this connection, but it’s an important thing to be mindful of if you’re using steroids for treatment.

By staying informed and aware of potential side effects, you can work with your healthcare provider to manage any issues that may arise. Knowledge is power, and understanding these potential risks can help you make more informed decisions about your health.

Recurrent Yeast Infections and VLS & What You Can Do To Manage

Experiencing a one-off yeast infection can happen to anyone, whether you have lichen sclerosus (LS) or not. However, if you find yourself dealing with recurrent yeast infections and suspect that your steroid medication might be a contributing factor, it’s crucial to have a conversation with your doctor. A healthcare provider who is knowledgeable about lichen sclerosus can help you find a solution that works best for you.

What Can Your Doctor Do?

Your doctor has several options to help manage and prevent recurrent yeast infections while you continue your steroid treatment. Here are some potential solutions:

Prescribe a Preventative Oral Antifungal: This can help keep yeast infections at bay. (Dr. Foster usually prescribes 6 months of weekly preventive fluconazole after a proven yeast infection, then culture again). 

Dr. Foster loves boric acid suppositories for anyone who has a disrupted vaginal microbiome. She uses 600mg suppository nightly x 1 week, then 2-3 nights per week. These are available on Amazon, and the main possible side effect is harming one’s partner if they perform oral sex on skin exposed to boric acid within the past 24 hours, so make a note of this. This is especially useful for C. glabrata, notes Dr. Babb.

Prescribe a Topical Antifungal: A topical treatment can be applied directly to the affected area to treat and prevent infections.

Compound a Topical Antifungal into Your Steroid Medication: This means combining both medications into one application, making it easier to manage.

Reduce the Potency of Your Steroid Medication: Lowering the strength of your steroid cream might help reduce the risk of yeast infections.

Reduce the Frequency of Your Steroid Medication: Using steroids less often can also help minimize the risk.

Prescribe an Alternative Treatment to Topical Corticosteroids: Options like calcineurin inhibitors (e.g., Pimecrolimus or Tacrolimus) can be effective without the same risk of yeast infections.

Open Communication is Key

This list is not exhaustive, and your doctor may have other suggestions tailored to your specific needs. Discussing your concerns and exploring these options together is The most important thing. By working closely with your healthcare provider, you can find a solution that works for you and your body.

Remember, you’re not alone in this, and there are ways to manage recurrent yeast infections while still effectively treating your lichen sclerosus.

Conclusion on Is Your VLS Flaring or Is It a Yeast Infection

In sum, navigating the complexities of yeast infections, especially when dealing with conditions like lichen sclerosus and steroid use, can be challenging. However, with your healthcare provider’s right knowledge and guidance, you can effectively manage and prevent recurrent infections. Remember, open communication with your doctor is key to finding a treatment plan that works best for you. You can take control of your health and well-being by staying informed and proactive. We hope this blog post has provided you with valuable insights and practical tips to help you on your journey. Stay healthy and informed!

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References

Fidel, Paul L., et al. “Candida Glabrata: Review of Epidemiology, Pathogenesis, and Clinical Disease with Comparison ToC. Albicans.” Clinical Microbiology Reviews, vol. 12, no. 1, 1 Jan. 1999, pp. 80–96, https://doi.org/10.1128/cmr.12.1.80. Accessed 19 Oct. 2020.

Goldstein, Andrew, et al. When Sex Hurts. Hachette Go, 3 Jan. 2023.

Lee, Andrew, and Gayle Fischer. “Diagnosis and Treatment of Vulvar Lichen Sclerosus: An Update for Dermatologists.” American Journal of Clinical Dermatology, vol. 19, no. 5, 9 July 2018, pp. 695–706, https://doi.org/10.1007/s40257-018-0364-7. Accessed 4 Mar. 2020.

Lowe, Nancy K., et al. “Accuracy of the Clinical Diagnosis of Vaginitis Compared with a DNA Probe Laboratory Standard.” Obstetrics & Gynecology, vol. 113, no. 1, Jan. 2009, pp. 89–95, www.ncbi.nlm.nih.gov/pmc/articles/PMC2745984/, https://doi.org/10.1097/aog.0b013e3181909f63. Accessed 16 Sept. 2019.

Renaud-Vilmer, Catherine, et al. “Vulvar Lichen Sclerosus.” Archives of Dermatology, vol. 140, no. 6, 1 June 2004, https://doi.org/10.1001/archderm.140.6.709. Accessed 24 July 2021.

Smith, Y. “Clobetasol Propionate in the Treatment of Premenarchal Vulvar Lichen Sclerosus.” Obstetrics & Gynecology, vol. 98, no. 4, Oct. 2001, pp. 588–591, https://doi.org/10.1016/s0029-7844(01)01496-x. Accessed 22 Nov. 2022.