Is there a link between isotretinoin (Accutane) and yeast infections?

Ask Dr. Jen

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Do you know anything about Accutane/isotretinoin causing repeated yeast infections? I started taking isotretinoin 2 months ago and I am suffering!!!

• Via The Vajenda

   

Some people might consider this is a niche question and think about scrolling on by if they aren’t taking isotretinoin, but I think you may find it informative how I approach a question when we have little published data to go on. Also, if you have unexplained vaginal symptoms, or believe you’ve been suffering with recurrent yeast, this may work as a basic guide for getting started. 

I’ve never heard of an association between isotretinoin, often known by the brand name Accutane, and yeast infections, so this question intrigued me. I see a lot of people with recurrent yeast infections, at least 5 or 6 people a week, and I don’t see many who are taking isotretinoin. It’s entirely possible there is an isotretinoin-yeast connection and isotretinoin isn’t a commonly prescribed where I practice. It’s also possible there’s a connection and those people can’t get referrals to me (this would make me sad) or that they’re self treating at home. I do see people taking isotretinoin who have vaginal irritation, but I’ve ruled out yeast as a cause.

My in-office experience is anecdotal and doesn’t exclude the possibility of an isotretinoin-yeast connection, so let’s take a deeper dive. 

I didn’t find anything in the medical literature or the package insert linking isotretinoin with vaginal yeast infections. I did find people online reporting recurrent yeast while taking isotretinoinm like the commenter above. However, without yeast cultures, it’s not possible to know who has been diagnosed accurately. This isn’t being dismissive, about 50% of people who think they have a vaginal yeast infection actually have another cause of their symptoms. I routinely see people who have been treated for years for yeast, and I make another diagnosis and then we get them the appropriate treatment. The first thing a doctor should do when faced with a medical condition that hasn’t responded appropriately to therapy is reconsider if the original diagnosis is correct. In addition, both yeast and isotretinoin can produce a sensation of vaginal dryness, and so it is possible to mistaken one for the other, meaning people could be over diagnosed with yeast or under diagnosed.

Thinking about the isotretinoin-yeast connection, there are three possibilities:

• Isotretinoin causes yeast infections.

• People who start isotretinoin are at higher risk for yeast for other reasons.

• Isotretinoin isn’t associated with yeast infections, but it causes vaginal symptoms mistaken as yeast.

Let’s look at the first scenario, isotretinoin causes yeast infections. As isotretinoin can dry the mucosa (the lining of the vagina), this could change the vaginal ecosystem in a way that favors yeast, and there are some reports of isotretinoin affecting bacterial colonization in the nose and on the skin. Meaning it’s biologically plausible that isotretinoin impacts the vaginal microbiome. 

Regarding the second possibility, people take isotretinoin for hard to treat acne, so it’s likely they’ve had a lot of antibiotics in the past, which is a risk factor for yeast. In addition, many are on the estrogen-containing birth control pill, because anyone who can get pregnant must be on contraception, and estrogen containing contraception increases the risk of yeast for some people. This is important, because if it were the history of antibiotics or the birth control pill stopping the isotretinoin wouldn’t help. 

Now let’s consider the third hypothesis, that vaginal dryness from isotretinoin is misdiagnosed as yeast. As already mentioned, approximately 50% of the time when people think they have a yeast infection, there is another cause for their symptoms. In addition, many health care providers misdiagnose yeast. Isotretinoin can cause vaginal dryness, so it can definitely cause symptoms.

It’s possible that people be experiencing more isotretinoin-related vaginal symptoms than previously. As mentioned previously, contraception is required to start isotretinoin, but years ago most people would have chosen the estrogen-containing birth control pill as fewer options were available, and I suspect the estrogen in the pill may counteract or at least partially help isotretinoin-induced vaginal dryness. We now have more highly effective non-estrogen methods of contraception, such as the implant and more IUDs, and so more people may be choosing these methods that don’t protect against isotretinoin side effects. 

The best way for an individual suffering with vaginal itch, irritation and/or burning to figure this out is to get a vaginal yeast culture, also called a mycology culture. A diagnosis of yeast should not be based on symptoms (meaning how you feel), by looking at the discharge, or by looking under the microscope. Vaginal microscopy is not well taught in most training programs and it’s easy for providers with less training to overcall yeast or to miss it. Also, skip the DNA tests, you need a culture. A culture is the gold standard and you deserve the gold standard. 

If the culture is negative when you have symptoms, it may be worth repeating a second time when symptoms return or a week or so later if symptoms persist, just to be sure. If the culture is negative a second time that it is highly unlikely the diagnosis is yeast and other causes of the vaginal symptoms should be explored. If a work up for bacterial vaginosis is negative and the symptoms started with the isotretinoin, I might suggest a regular vaginal moisturizer or low dose vaginal estrogen for someone not on an estrogen containing pill, but it really would depend on what I saw looking at the vulva and vagina and what I see looking at a vaginal sample under the microscope. Overall, there is little (if any) risk of harm with a three month trial of vaginal estrogen.

If the culture is positive for yeast, there are two possibilities. Yeast is causing the symptoms OR yeast isn’t causing the symptoms. This may surprise some people, but up to 20% of yeast cultures are positive for people who don’t have any symptoms (I call this bystander yeast). To determine if yeast is the issue or not, I recommend treating the yeast, but with a prolonged treatment so people have time to decide if they are truly better or not.

The regimen I would use, assuming Candida albicans on the culture, the most common yeast, is as follows:

• Fluconazole 150 mg on day 1 and again on day 4, and then once a week thereafter for three months. 

• On day 21-ish (this could be anywhere from day 14-28) I see people back in the office to make sure they are 100% better and recheck their yeast culture. If they are cured and the yeast culture is negative, we have the answer. It’s yeast. If someone has had three or more infections in the past 12 months, I would leave them on the weekly fluconazole for at least six months. If the symptoms haven’t gone, but the culture is negative, then it’s likely the yeast wasn’t playing a role, or at least not a significant one. In this scenario. I might still suggest taking the weekly fluconazole medication for the full three months while we work up the cause of the symptoms so intermittently positive yeast cultures that can happen “just because” don’t return and confuse the picture. 

If there is yeast and treating it takes the symptoms away, it doesn’t tell us for sure if the cause was the isotretinoin, but if there were no recent history of antibiotics and this started two months after starting the medication, I’d definitely be concerned. Regardless of the cause, we would treat it for six months if infections have been recurrent. If someone wants to stop isotretinoin to see if that helps, obviously that’s also a choice, but people who are taking this medication are doing so for a reason, meaning other therapies haven’t worked, and so I want to support them in any way that I can. 

There is one other scenario to consider. Someone who has been suffering with one long, continuous yeast infection since starting isotretinoin. Here I’m assuming the yeast culture is positive. The fluconazole has been started, but at the follow-up visit the culture will still be positive. In this scenario the yeast is resistant to standard medications, so it’s not a recurrent infection, it never went away to begin with. In this situation, I would want the culture to be tested for sensitivities, so I have an idea of what other options to consider. While it’s possible that the isotretinoin caused the yeast infection, and it was just bad luck that it’s a resistant one, it’s also possible that it was just bad luck that a yeast infection developed right after starting the isotretinoin and bad luck that it’s resistant.

Resistant yeast is another long topic, and if it’s something you want to hear more about, leave a comment or hit the like button.

So that’s my rather long-winded answer about the possible link between isotretinoin and vaginal yeast infections and how to work through the issue if you are suffering. Also, we don’t normally check liver function tests to start fluconazole, but as isotretinoin can affect the liver, you want to make sure this testing is normal and have a discussion with your own provider before starting. If the oral medication isn’t an option, over the counter clotrimazole can be used (I prefer it because it tends to be less irritating than the other topicals). Treat for a week and then once a week for three months, also doing the cultures as described above. 

I’m going to poke around some more and see what I can find, but I hope this helps!

As a side note, I think it’s unacceptable that we don’t have vaginal culture data for many medications. This should be part of clinical trials. We have no idea if something could affect the microbiome unless we check. 

Also, when looking for questions to answer, I try to pull from the comments on my Substack. So keep them coming!