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Yeast Infection or Lichen Sclerosus: Why So Many Misdiagnoses?

Yeast Infection or Lichen Sclerosus: Why So Many Misdiagnoses?

Introduction

A common thread in lichen sclerosus diagnosis stories is multiple misdiagnoses. One of the most common misdiagnoses that folks with lichen sclerosus get is yeast infections. These misdiagnoses can lead to years of delayed diagnosis, which, consequently, can lead to the progression of LS and a worsening of symptoms. Therefore, knowing the differences between lichen sclerosus and yeast infections is important. This post is part educational and part to help build awareness so that healthcare providers will have an easier time determining if a patient has lichen sclerosus or a yeast infection (or both).

This post discusses what a yeast infection is, its signs and symptoms, diagnosis, and treatment. I also share my thoughts on why I think LS is commonly misdiagnosed as lichen sclerosus. In our next blog post, I’ll dive deeper and discuss complicated and recurrent yeast infections, the connection between steroids and yeast infections, and what to do if you suspect you have a yeast infection; stay tuned!

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.

**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.

What is a Yeast Infection

Yeast is a fungus that can be found on the skin and digestive tract. It is normal for humans to have certain amounts of yeast in the body. However, if the yeast grows too much, it can lead to a yeast infection (aka candidiasis, yeast vaginitis, or vaginal candidiasis). A common area of the body for this infection to occur is the vagina. However, you can also get yeast infections in the mouth, vulva, or peri-anal skin. 

Graphic design image of a wet mound (specialized microscope) and a sample under the microscope which is part of diagnosing yeast infections.

Most yeast infections are caused by candida albicans fungus. However, infections caused by candida glabrata fungus are on the rise (Goldstein, Pukall, Goldstein, and Krapf, 2023). 

Yeast infections are common, with approximately 75% of people with vulvas/vaginas having reported at least one infection in their lifetime (ibid). Further, up to 10% of that population experiences recurrent yeast infections (defined as having four or more infections in a year) (Wong, 2023). 

While yeast infections can occur in different areas of the body, this blog focuses on vulvovaginal yeast infections.

Signs and Symptoms of Vulvovaginal Yeast Infections

Signs and symptoms of vulvovaginal yeast infections can include:

  • Thick, clumpy discharge from the vagina–can be white, yellow, or green (*may not be present if the infection is only affecting the vulvar skin)
  • Itching (either vulvar and/or vaginal)
  • Burning (either vulvar and/or vaginal)
  • Soreness (either vulvar and/or vaginal)
  • Redness of the vulva (often the labia minora, the opening of the vagina, etc.)
  • Swelling of the labia/vulva
  • Pain when urinating
  • Pain with sex
  • Fissures 
  • Satellite lesions in the vulva and around the groin/upper thighs and perianal skin.

(Goldstein, Pukall, Goldstein, and Krapf, 2023; Gonçalves et al., 2016; Sobel, 2005; Vieira-Baptista and Borstein, 2019).

Risk Factors for Yeast Infections

Let’s talk about risk factors for a moment. Risk factors are things that increase the likelihood of you developing a condition, disease, or infection, such as a yeast infection

Here are some of the commonly cited risk factors for yeast infections:

  • Antibiotic use
  • Wet, damp, and humid environments (this is why gynecologists tend to tell folks not to sit around in a wet bathing suit or to shower and change their clothes after a sweaty workout at the gym)
  • Hormonal changes (due to pregnancy, birth control, estrogen therapy, etc.)
  • Vaginal douching
  • Diabetes mellitus
  • Genetics
  • Steroids and immunosuppressants 

Yeast Infection Classification

Vieira-Baptista and Borstein (2019) outline three main categories of yeast infections–uncomplicated, complicated, and recurrent. Uncomplicated cases are infrequent or one-off infections with mild-moderate symptoms caused by candida albicans in non-immunocompromised people (Vieira-Baptista and Borstein, 2019). Complicated cases involve severe symptoms (e.g., vulvar swelling and fissures) that may or may not be caused by non-albicans species of yeast and may or may not occur in people who are pregnant, have diabetes, or are immunocompromised (ibid). Finally, recurrent cases are defined as having four or more yeast infections yearly (ibid). 

Diagnosis

Ideally, yeast infections are diagnosed by swabbing the vagina and/or vulva and examining the discharge/secretions under a microscope, and measuring the PH of the vagina (Goldstein, Pukall, Goldstein, and Krapf, 2023; Viera-Baptista and Bornstein, 2019).

Graphic design image of a wet mound (specialized microscope) and a sample under the microscope which is part of diagnosing yeast infections.

Important Notes on Yeast Infection Diagnoses

It is possible to have a vulvar yeast infection or infection of the perianal skin. If your doctor only swabs the vagina, this can be missed. Be sure to insist they swab the vulvar and perianal skin for testing as well.

When Possible, Say ‘NO’ to Self-Diagnoses

We understand the allure of self-diagnosis. For one thing, depending on where you live in the world, seeing a doctor can take weeks if not months. Therefore, getting a clinical diagnosis by a doctor in person is not an option for everyone. However, if the option is available and accessible to you, we always recommend getting diagnosed by a healthcare professional.

Why? Well, for one thing, self-diagnosis of yeast infections is wrong in up to 90% of cases (Ferris et al., 1996; Sobel, 2007).

Further, in-person visits with a healthcare provider who will perform swab testing and PH testing are preferred over telehealth diagnosis. The reason is that just as self-diagnoses are unreliable, so are clinical diagnoses without testing. A study by Lowe et al. 2009 showed that healthcare providers who give a clinical diagnosis–i.e., give the diagnosis based on symptoms and examination of the vulva/vagina–are wrong approximately 20% of the time.

False Negatives

It’s important to note that false negatives can occur with microscope testing (Goldstein, Pukall, Goldstein, and Krapf, 2023). If you strongly suspect a yeast infection and your test results are negative, ask your healthcare provider to perform a fungal culture to confirm (ibid). 

Treatment

Treatments range from topical antifungal creams to oral antifungal medications. Many specialists prefer oral antifungals over topicals, as topicals can cause vulvar irritation for some individuals. Common oral antifungals are voriconazole (Vfend) and fluconazole (Difulcan) (Goldstein, Pukall, Goldstein, and Krapf, 2023).

Graphic image of a bottle of pills and a tube of ointment, representing topical and oral antifungal medication for the treatment of yeast infections.

More on the treatment of complicated or recurrent yeast infections in two weeks!

Lichen Sclerosus or Yeast Infection? Why Are Misdiagnoses so Common?

The scientific literature shows that one of the most common misdiagnoses people with lichen sclerosus get is a yeast infection (Arnold et al., 2022; Krapf et al., 2022). We at LSSN hear about this all the time at our virtual meetups. Indeed, we hear countless stories of people being told their vulvar itch and pain was due to a yeast infection, only to discover years later it was actually LS.

So why are misdiagnoses of yeast infections so frequent?

Well, for one thing, and this is just my (Jaclyn’s) opinion since yeast infections are so common–affecting approximately 75% of people with vulvas/vaginas, many healthcare providers may think of that before considering less common conditions. Remember that the prevalence of LS is unknown, and statistics vary per paper, but it is considerably less common than 75%.

Lack of Education and Training

Secondly, while most healthcare providers–general physicians/family doctors, nurses, and gynecologists–have received proper education and training with respect to yeast infections, they typically receive less time on vulvar conditions such as lichen sclerosus. In fact, I’ve spoken to many family doctors who said they barely remember it being discussed in grad school. We at LSSN often get nurses who are diagnosed with LS and mad that they never learned about it in school. 

Furthermore, if healthcare providers do not receive adequate education and training on lichen sclerosus, they may not recognize clinical signs of lichen sclerosus, such as architectural changes, hypopigmentation (loss of pigmentation), and skin thickening. This is, again, in my (Jaclyn’s) opinion, a huge problem because the main differentiating factor between LS and a yeast infection is the clinical signs (since symptoms are so similar).

Graphic image of an open textbook surrounded by a pen, a calculator, a globe, a graduate degree hat, science equipment and a lightbulb representing the importance of good healthcare provider education and awareness of vulvovaginal conditions.

If healthcare providers are not getting adequate training and education to recognize the clinical signs and symptoms of LS, they likely will miss the diagnosis altogether. This can lead to big delays in diagnosis. We at LSSN are working hard behind the scenes to change this for future generations to help individuals with LS get diagnosed earlier.

Lichen Sclerosus and Yeast Infections

At this point, you may wonder if there are any important connections between lichen sclerosus and yeast infections. For example, you may have noticed steroids/immunosuppressants are listed as a risk factor for yeast infections. Therefore, you may wonder if your LS medication is causing yeast infections. Our next blog post will address this and recurrent/complicated yeast infections and LS next week!

Conclusion on Lichen Sclerosus or Yeast Infection

In sum, yeast infections are common–affecting up to 75% of people with vulvas/vaginas. Yeast infections occur when there is an overgrowth of yeast in the vulva/vagina, causing unpleasant symptoms like burning and itching. Diagnosis is ideally given in person, with a healthcare provider examining the vulvovaginal secretions under a microscope and checking PH levels. Standard treatment involves either topical or oral antifungal medications.

In our next post, we will take a deeper dive into this topic, looking at complicated cases of yeast infections, recurrent yeast infections, the connection between LS, steroids, and yeast infections, and what to do if you suspect yeast.

Let us know if you were misdiagnosed as having a yeast infection/chronic yeast in the comment section below.

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Reach Out to Me

Whether you are debating booking a support call with me, have a quick question, or want to share something related to my content, I can be reached via:

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Support Resources

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Feel free to book a 1:1 call with me if you struggle with grief and emotions. Simply click this link to learn more about lichen sclerosus peer support calls.

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For a more detailed list of free and paid support resources, check out my LS resources page here.

References

1.Lowe NK, Neal JL, Ryan-Wenger NA. Accuracy of the Clinical Diagnosis of Vaginitis Compared With a DNA Probe Laboratory Standard. Obstetrics & Gynecology. 2009;113(1):89-95. doi:https://doi.org/10.1097/aog.0b013e3181909f63

2.Goldstein A, Pukall C, Goldstein I, Dr. Jill Krapf. When Sex Hurts. Hachette Go; 2023.

3.Gonçalves B, Ferreira C, Alves CT, Henriques M, Azeredo J, Silva S. Vulvovaginal candidiasis: Epidemiology, microbiology and risk factors. Critical reviews in microbiology. 2016;42(6):905-927. doi:https://doi.org/10.3109/1040841X.2015.1091805

4.Vieira-Baptista P, Bornstein J. Candidiasis, Bacterial Vaginosis, Trichomoniasis and Other Vaginal Conditions Affecting the Vulva. Vulvar Disease. Published online 2019:167-205. doi:https://doi.org/10.1007/978-3-319-61621-6_24

5.Ferris DG, Dekle C, Litaker MS. Women’s use of over-the-counter antifungal medications for gynecologic symptoms. The Journal of Family Practice. 1996;42(6):595-600. Accessed October 31, 2023. https://pubmed.ncbi.nlm.nih.gov/8656170/#:~:text=Based%20on%20our%20findings%2C%20women

6.Arnold S, Fernando S, Rees S. Living with vulval lichen sclerosus: a qualitative interview study. British Journal of Dermatology. 2022;187(6):909-918. doi:https://doi.org/10.1111/bjd.21777

7.Krapf JM, Smith AB, Cigna ST, Goldstein AT. Presenting Symptoms and Diagnosis of Vulvar Lichen Sclerosus in Premenopausal Women: A Cross-Sectional Study. Journal of Lower Genital Tract Disease. 2022;Publish Ahead of Print. doi:https://doi.org/10.1097/lgt.0000000000000679

8.Sobel, JD. (2005). Genital candidiasis. Medicine, 33:62–5.

9.Sobel JD. Vulvovaginal candidosis. Lancet. 2007 ;369:1961–71.

2 Comments

  • I’m currently waiting for a biopsy result that will tell me if I have LS or not. I’m 26, was so called diagnosed with LS after a yeast infection 4 years ago when I was 22. The last 4 years I’ve had flare ups and nothing ever really got better, even with using Clobetasol propionate cream. My first doctor never did a biopsy, she just said I had it, gave me the steroid cream and sent me on my way. We moved and I just took the diagnosis and have been using it as needed the last 4 years. But was so confused and in pain. Recently my symptoms have gotten worse and I found a new gyno in my new state and she told me she doesn’t think I even have LS. We tried a yeast infection treatment with nystatin/steroid for 30 days and it helped but upon stopping, everything came back 10 fold. So we did a biopsy to rule out LS and I’m now on a nystatin powder to see if drying out the area helps treat the yeast infection. Don’t know if I have yeast infection or LS cause nothing seems to be working. I could have been having chronic yeast infections due to misdiagnosis of LS and my steroid cream was doing more harm than good. Could be a steroid withdrawal from the strong steroid cream I was using for my LS. I don’t know. So I’m having the opposite experience of this post which has been super discouraging. But I still find LSS so great and helpful! You guys have literally brought a little hope into my life seeing that there are many other women who are struggling with lady part problems. I’m nervous the biopsy isn’t going to clearly diagnose what is wrong, seeing as I’ve been struggling for 4 years and doctors say the same thing. I’m hoping and praying it does give me some sort of answer. Super frustrating! Thank you for your blogs and posts!

    • Jaclyn Lanthier

      Hi, Sarah. Thank you so much for sharing your journey with us, and wow, I’m so so so sorry for everything you have been through. Vulvar conditions are notoriously hard to diagnose because there are so many overlapping symptoms. I hope the nystatin powder helps, or that you can get some relief (and, honestly, some answers) soon. Have you had your biopsy yet or when is it scheduled for?

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