Can prednisone (corticosteroid) cause yeast infections, especially in patients with compromised immune systems or underlying medical conditions such as diabetes?

Does Prednisone Cause Yeast Infections?

Yes, prednisone and other corticosteroids significantly increase the risk of yeast infections, particularly Candida species, by suppressing immune function and altering the body's ability to resist fungal pathogens. 1

Mechanism of Increased Risk

The FDA drug label explicitly warns that corticosteroids, including prednisone, suppress the immune system and increase the risk of infection with fungal pathogens. 1 Specifically, corticosteroids:

• Reduce resistance to new infections 1
• Exacerbate existing fungal infections 1
• Increase risk of disseminated infections 1
• May mask signs of infection, making diagnosis more difficult 1

The FDA further states that corticosteroids may exacerbate systemic fungal infections and should be avoided in the presence of such infections unless needed to control drug reactions. 1

Clinical Evidence

Chronic corticosteroid use substantially increases both the frequency and severity of vulvovaginal candidiasis (VVC). Research demonstrates that chronic corticosteroid users experience:

• More frequent recurrent VVC episodes (65.9% vs 40.4% in non-users) 2
• Significantly higher rates of non-Candida albicans infections (48% vs 20%), which are more difficult to treat 2
• Increased antifungal resistance, particularly to clotrimazole and ketoconazole 2

The CDC guidelines specifically identify women receiving corticosteroid treatment as having compromised host status who do not respond as well to short-term antifungal therapies. 3

Dose and Duration Considerations

The risk of fungal infections increases with both dose and duration of corticosteroid therapy. The Journal of Crohn's and Colitis reports that:

• Prednisolone doses ≥20 mg daily for ≥2 weeks are associated with increased infection risk 3
• Corticosteroid use was more commonly associated with fungal (Candida species) infections compared to other immunosuppressants 3
• The rate of infectious complications increases with increasing corticosteroid dosages 1

High-Risk Populations

Certain patient groups face particularly elevated risk:

• Patients with diabetes: Already prone to genital mycotic infections due to high blood glucose levels promoting yeast growth; corticosteroid use compounds this risk 4, 5
• Immunocompromised patients: Including those with HIV, where vaginal Candida colonization rates correlate with immunosuppression severity 3
• Patients on combination immunosuppression: Risk increases substantially when corticosteroids are combined with other immunosuppressive medications 3

Clinical Management Algorithm

When prescribing prednisone, follow this approach to minimize fungal infection risk:

1. Pre-treatment screening: Screen for existing fungal infections before initiating therapy 6, 7

2. Risk stratification: Identify high-risk patients (diabetes, immunocompromised, prior fungal infections) who may benefit from prophylaxis 7

3. Dose optimization: Use the minimum effective corticosteroid dose to achieve clinical goals 8

4. Active monitoring: Continuously monitor for signs of fungal infection during and after treatment, recognizing that symptoms may be masked 1

5. Prompt treatment: If fungal infection develops:

   • Women with compromised host status require prolonged (7-14 days) conventional antimycotic treatment rather than short courses 3
   • Consider non-albicans species and potential azole resistance in chronic corticosteroid users 2
   • Efforts to correct modifiable conditions (e.g., glycemic control in diabetes) should be made 3

Critical Pitfalls to Avoid

• Do not dismiss recurrent yeast infections in corticosteroid users as simple nuisance infections; they may represent non-albicans species requiring different treatment 2
• Do not use standard short-course antifungal therapy in corticosteroid-treated patients; extended treatment (7-14 days) is necessary 3
• Do not overlook the possibility of systemic fungal infections, particularly invasive aspergillosis, which occurred in 16% of patients with severe alcoholic hepatitis treated with corticosteroids during three-month follow-up 6, 7
• Do not assume standard azole antifungals will be effective; chronic corticosteroid use increases resistance to clotrimazole and ketoconazole 2