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THE FOLLOWING MEDICAL AND SCIENTIFIC MATERIAL IS FOR CONSUMER INFORMATIONAL AND EDUCATIONAL PURPOSES ONLY UNDER SECTION 5 OF DSHEA.

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Candida

Candida is the yeast that can cause problems throughout the digestive tract including thrush in the mouth, esophagitis in the throat, and yeast overgrowth in the lower intestine. Candida overgrowth can also result in anal itching.

  • Introduction

    Candida albicans is a normal inhabitant of the gastrointestinal (GI) tract. Usually, the "good" bacteria in the GI tract keep the growth of this yeast in check, and it does not cause problems. However, in some people various factors contribute to Candida overgrowth (candidiasis). More serious conditions related to Candida overgrowth tend to occur in people with compromised immune function. This is seen in people living with HIV infection, and in people being treated with immunosuppressive drugs (including cancer therapies), and drugs used to treat autoimmune diseases. Candida overgrowth may also occur in people living with diabetes and CFIDS (Chronic Fatigue and Immune Dysfunction Syndrome).

    Several factors can contribute to the development of Candida overgrowth, including the frequent use of antibiotics. Antibiotics are prescribed to destroy bacteria that cause infections. Unfortunately, while destroying these disease-causing bacteria, they also destroy some of the "good" bacteria in the intestines and the vagina. When there is Candidaovergrowth in the intestinal tract, the most common symptoms are anal itching, and excessive gas, bloating, or belching, especially after sugars or starches are eaten. The latter occurs because simple sugars are a source of food for the yeast and stimulate their activity and growth, resulting in the excess gas formation. Alternating constipation and diarrhea can also be present, as can diarrhea alone.

    In people with compromised immune function, Candida overgrowth can result in a thick white or yellowish coating on the tongue called thrush (pseudomembranous candidiasis) which in some cases extends down into the esophagus, where it is called esophageal candidiasis, a condition that can cause pain on swallowing or an uncomfortable feeling of choking. Less common manifestations of Candida include atrophic (erythematous) candidiasis, a condition in which non-painful red or bare areas appear on the tongue, inside the cheeks, or on the hard or soft palate; angular cheilitis which causes cracks or ulcers in the mouth; and hyperplastic candidiasis which can appear as either red or white lesions anywhere in the mouth.

    In people who wear dentures, chronic atrophic candidiasis (denture stomatitis) may develop. This is one of the most common forms of Candida overgrowth. Symptoms may include redness and swelling of the portion of the palate that comes into contact with dentures.

  • Lifestyle Factors

    One very useful step that may help eliminate Candida overgrowth in the GI tract is to cut down on consuming starches and sugars.Research has shown that sugar stimulates the growth of Candida albicans, from the mouth to the intestines. In a study with yeast-infected mice, it was shown that those fed sugar-water had greatly increased amounts of yeast in their stools compared to mice fed either water containing a sugar substitute (xylitol) or water with no sweetener at all.1

    The researchers also showed that when these mice were treated with chemotherapy to suppress their immune systems, the amount of yeast in the stool samples of the mice fed the sugar-water increased dramatically compared to no change to the other groups of mice. Eighty percent of the mice who had been fed the sugar water had detectable yeast in the intestines, whereas 90% of the mice fed either the sugar substitute or no sweetener at all had either no detectable yeast. The difference between the sugar-fed group and the other groups was highly statistically significant.

    The researchers in this study also showed that the intestines of the mice which had been fed the sugar-water had yeast that was able to penetrate their intestines and enter the blood.

    Eliminating sugar from the diet, along with the countless foods that contain it, may be a very important intervention for helping to reverse Candida overgrowth and regain balance in the GI tract. For someone currently experiencing the symptoms of GI tract Candida overgrowth, it is best to at least temporarily eliminate all simple sugars from the diet, including all foods made with any form of sugar, maltose (found in beer, malted snacks, some cereals, and some crackers), honey and other natural sweeteners, fruit, and fruit juice. Because milk also contains the simple sugar called lactose, avoiding milk and most other dairy products would also be wise during this period. The only exception would be yogurt since it contains the good bacteria that can actually help to counter yeast overgrowth. Your diet should emphasize vegetables and protein with moderate amounts of fat and a sufficient amount of complex carbohydrates (such as brown rice or whole grains) to avoid weight loss. The idea is to starve the yeast as much as possible while at the same time you take in substances that will help to destroy them.

    While it is true that complex carbohydrates do eventually break down into simple sugars, this conversion occurs farther down in the digestive tract where the body has better controls against Candida growth. Complex carbohydrates are long-chain starches which are changed by salivary enzymes into dextrin, a short-chain starch, in the mouth. However, the conversion to simple carbohydrates—first maltose and then glucose—occurs in the small intestine. By avoiding the simple sugars you avoid feeding the yeast in the mouth and esophageal area where it too often causes problems, especially in the immune compromised host.

    It may be very useful to combine these dietary changes with taking other measures such as probiotics supplements or antifungals or other therapeutic agents to suppress yeast overgrowth. However, in general, once the Candida overgrowth has been eliminated it will be best to again include fruits since they are good sources of important vitamins and minerals, as well as fiber. For anyone with a history of Candida overgrowth, abstaining from pure sugar, and processed foods containing it, is an excellent long-term suggestion.

  • Standard Medical Therapies

    There are a number of medications approved by the FDA for the treatment of serious Candida overgrowth. Oral Candida overgrowth may be treated with either topical antifungal agents (such as nystatin, clotrimazole, or amphotericin B oral suspension) or systemic medications (fluconazole, itraconazole). In people with compromised immune function, especially HIV-positive people, there can be a slower response to the drugs, and a higher rate of recurrence. In some people with advanced HIV disease, the overgrowth may not respond well to treatment. In these people, it is generally advised that highly active antiretroviral therapy (HAART) be started (if the person is not yet on it) in order to help restore immune function. In addition, higher dosages of fluconazole (as high as 800 mg per day) or itraconazole (as high as 600 mg per day) or intravenous amphotericin B may be needed. These are extreme measures that should be reserved for extreme cases.

    Candida in the lower gastrointestinal tract (including the esophagus, stomach, and small or large intestine) is treated systemically, most commonly with fluconazole or itraconazole continued for at least 2-3 weeks. Intravenous fluconazole may be needed in those who cannot take oral medication. Voriconazole and micafungin were recently approved for retractable esophageal candidiasis treatment.

    Azoles are potent antifungal agents. Triazole agents. The most commonly used azoles include fluconazole (Diflucan) and itraconazole (Sporanox). These drugs are highly effective for suppressing Candida overgrowth but with repeated or long-term use, drug resistance often develops. Newer azoles, including voriconazole (Vfend), posaconazole (Noxafil), and ravuconazole may be active against strains of Candida that have become resistant to fluconazole or other antifungals. The older drug ketoconazole is now less used since it is thought to generally be less effective. Drugs in this class can cause a long list of side effects, including most commonly nausea, vomiting, diarrhea, and allergic reactions. Less common but much more severe side effects include serious liver toxicity, severe hypersensitivity reactions (including Stevens-Johnson syndrome), visual disturbances, respiratory disorders, high blood pressure, and heart complications. The azole drugs also interact with many other medications. Clotrimazole (Mycelex, Femizole-7) can be used in lozenge form as a treatment for Candida overgrowth in the mouth.

    Polyenes are broad-spectrum antifungal medications that include amphotericin B (Fungizone, Amphocin) and liposomal amphotericin B formulations (Amphotec, Abelcet, AmBisome). These drugs are effective for treating serious Candida overgrowth but the intravenous forms can cause very serious side effects, including fever, chills, rigors, nausea, vomiting, high blood pressure, abnormal heart rhythm, and serious kidney and liver toxicity. Amphotericin B oral suspension can be used to treat Candida overgrowth in the mouth and throat. Another polyene is topical nystatin (Mycostatin), used as a lozenge to treat Candida overgrowth in the mouth or throat. Side effects of nystatin may include nausea, vomiting, and diarrhea.

    Glucan synthesis inhibitors (echinocandins) include caspofungin (Cancidas), micafungin (Mycamine), and anidulafungin ((Eraxis), all of which are approved for the treatment of esophageal candidiasis, as well as more serious systemic forms of candidiasis. These drugs must be given intravenously. Common side effects include headache, nausea, vomiting, abdominal pain, and headache. Less common but more severe side effects include kidney and liver toxicity and worsening of pre-existing bone marrow suppression.

  • Beneficial Nutrients

    Ensuring that the gastrointestinal tract is well populated with the "good" bacteria that normally keep Candida in check is almost certainly the most important natural therapy that is available. In addition, there are a number of natural remedies that may help suppress Candida overgrowth.

    Probiotics supplements contain the "good" bacteria that help keep the GI tract healthy. Naturally occurring intestinal microorganisms such as Lactobacillus acidophilus, Bifidobacterium bifidum, and others aid digestion and produce nutrients for the body. They also keep potentially harmful microorganisms in check by providing a counterbalance against their growth. Healthy bacteria also provide a protective layer along mucous membranes that helps prevent the attachment of the "bad" bacteria and fungal organisms that can cause disease.2 If the attachment sites in the intestine are occupied by the good bacteria, then those sites are not available for other organisms to use. In addition, the healthy bacteria produce substances that work against disease-causing organisms.3 For example, when healthy bacteria work to break down food in the intestines, lactic acid, hydrogen peroxide, and other byproducts are produced that make your intestinal environment hostile for undesired organisms, helping to suppress their growth.

    Many studies have shown the potential usefulness of probiotic supplementation, both for the maintenance of good health and for the prevention of disease. Probiotics supplements that contain the good bacteria can be used to help prevent yeast overgrowth in people taking antibiotics by replacing the good bacteria destroyed by the drugs. In a trial in which people were treated with potent antibiotics, supplementing with probiotics during treatment was shown to help restore intestinal bacteria.4 In a review that looked at randomized controlled trials, it was found that there is strong evidence from multiple studies supporting the benefits of probiotics for the prevention or treatment of antibiotic-associated disorders.5 Studies have also shown that supplementation with products containing healthy bacteria results in a reduction of the Candida population in the GI tract.6,7 In patients undergoing chemotherapy, supplementation with probiotics has been shown to reduce the incidence of intestinal Candida overgrowth.8 In the elderly, where oral Candida overgrowth is common, it has been shown that consuming cheese, which contains probiotics, can reduce the risk of high yeast counts by 75%.9 Probiotics can provide benefit even in those being treated with antifungals to suppress Candida. When the antifungals kill off the overgrowth of Candida, probiotic supplements can help repopulate the intestinal tract with healthy bacteria that can help prevent the return of the Candida.

    Probiotics supplements are available in capsules, powders, granules, and liquid forms.

    Coconut oil, caprylic acid, capric acid, and lauric acid have been shown to have significant antifungal activity. The active ingredients in coconut oil that have antifungal effects are caprylic acid, capric acid and lauric acid. Caprylic acid is the common name for the eight-carbon saturated medium chain fatty acid known by the systematic name octanoic acid. It is found naturally in oils derived from palm, hemp, coconut, and other plants, as well as in breast milk. Research many years ago showed that caprylic acid has antifungal properties.10 One study found that it could be successfully used for the treatment of intestinal Candida overgrowth.11 It has long been recommended by nutritionists and naturopathic physicians as a natural therapy for the treatment of Candida overgrowth, most commonly in doses of 500 to 1,000 mg, three times daily. Caprylic acid is nontoxic, but may lose its effectiveness over time, especially with long-term use. The other active ingredients in coconut oil have also been shown to have strong anti-Candida activity. In one study, capric acid, a 10-carbon saturated fatty acid, was reported to result in the fastest and most effective killing of all three strains of C. albicans tested, while lauric acid, a 12-carbon saturated fatty acid, was the most active against the Candida strains at lower concentrations and after a longer incubation time.12 More recent research has shown that coconut oil itself has potent activity against Candida. In a recent test-tube study, pure coconut oil was reported to be as effective as fluconazole in suppressing Candida.13 Organic coconut oil and supplements containing its active ingredients are available in most natural foods and supplement stores. It is important to choose an organic coconut oil that is cold pressed from fresh coconut meat, rather than one made from copra, a dried coconut meat that is heavily refined and may contain trans fats.

    Garlic has long been used as a natural therapy to suppress Candida overgrowth. Both animal and test tube studies have shown that it has potent antifungal activity against Candida albicans.14,15,16,17 However, one small trial found that in concentrations high enough to have significant anti-Candida effects, a freshly prepared garlic extract caused serious indigestion and burning sensations in the mouth, esophagus, and stomach.18 The duration of the antifungal effects was quite short (lasting only one hour), and study participants were too bothered by the side effects to want to take multiple doses daily. Thus, although the antifungal effects of garlic were confirmed in this study, the results make practical use of this type of garlic extract difficult. This study also showed that a commercially available garlic capsule had no antifungal activity. Use of fresh garlic in the diet may provide modest anti-Candida activity that might help to prevent the development of Candida overgrowth, but in the amounts which are tolerable, may not provide truly significant effectiveness for suppressing already present Candida overgrowth.

    Grapefruit seed extract, found in numerous over-the-counter products, has antifungal effects that may help suppress Candida overgrowth. It is not absorbed from the intestinal tract and has shown no toxicity except for a concentration-dependent local irritant effect. It should not be used by anyone allergic to citrus fruit. It is available in both capsules and liquid form. If used as a liquid, it must be well diluted because the straight preparation is very irritating to mucous membranes. It also has a bitter taste which can be covered up by diluting it in vegetable juice.

    Oregano oil has been found to have antifungal effects. Research has shown that it has particularly potent activity against Candida albicans.19,20 In one small study (not yet published) of people suffering from Candida overgrowth (as evidenced by stool, vaginal, and throat cultures), oregano extract was shown to significantly decrease the overgrowth. Prior to the treatment, all ten people had either moderate, severe, or maximal Candida growth on cultures. Six out of ten had maximal growth on both stool and throat cultures. After four weeks of treatment (one tablet given four times per day after meals, for the first week; followed by two tablets given four times per day after meals for the last three weeks), six people's lab cultures showed no remaining Candida and three people had a 50% or greater reduction in their counts. Only one person showed no change. All those in the study reported symptomatic improvement, including improved energy, increased appetites, and lessened insomnia. There were no side effects reported in this study. However, there have been sporadic reports of indigestion, especially with higher doses. Enteric coated capsules are best to help reduce the possibility of these side effects.

    Tea tree oil has been shown in test tube studies to potently suppress Candida.21 One tea tree product, an oral melaleuca suspension commonly sold as a mouthwash called Breathaway, contains an oil derived from the paper bark tea tree found in coastal eastern Australia which has known antifungal activity. In a small trial of HIV-positive people with fluconazole-resistant thrush, the use of this mouthwash as a 60-second swish and spit solution resulted in improvement in ten out of twelve people after four weeks (and 7 out of 12 in only two weeks).22 In five of the 12 people, there was complete elimination of all lesions. During a four-week follow-up period, there were no relapses. The melaleuca solution caused a burning feeling in 75 percent of those using it, and nausea in one person (who mistakenly swallowed the solution rather than spitting it out). For use of tea tree oil as a mouthwash, nothing more potent than a 5% solution(1 part tea tree oil: 20 parts water) should be used, and it should not be swallowed.

  • References

    1. Modulating effect of dietary carbohydrate supplementation on Candida albicans colonization and invasion in a neutropenic mouse model. Infection and Immunity. 1993;61:619-626. Vargus SL, Patrick CC, Ayers G, Hughes WT.

    2. The role of probiotic cultures in the control of gastrointestinal health. J Nutr. 2000;130 (2S Suppl):396S-402S. Rolfe RD.

    3. The role of probiotic cultures in the control of gastrointestinal health. J Nutr. 2000;130 (2S Suppl):396S-402S. Rolfe RD.

    4. Impact of Lactobacillus acidophilus on the normal intestinal microflora after the administration of two antimicrobial agents. Infection. 1988;16(6):329-336. Lidbeck A, Edlund C, Gustafsson JA, et al.

    5. Probiotics and intestinal health effects: a clinical perspective. Br J Nutr. 2002;88 Suppl 1:S51-7. Marteau P, Seksik P, Jian R.

    6. Variations in intestinal candida populations in patients receiving antileukemic therapy. Bulletin of the Osaka Medical School. 1984;30(1):14-18. Tomada T and Nakano Y.

    7. Intestinal Candida overgrowth and Candida infection in patients with leukemia: effect of Bifidobacterium administration. Bifidobacteria Microflora. 1988;7(2):71-74. Tomoda T, Nakano Y, Kageyama T.

    8. Variations in intestinal candida populations in patients receiving antileukemic therapy. Bulletin of the Osaka Medical School. 1984;30(1):14-18. Tomada T and Nakano Y.

    9. Probiotics reduce the prevalence of oral Candida in the elderly—a randomized controlled trial. J Dent Res. 2007;86(2):125-130. Hatakka K, Ahola AJ, Yli-Knuuttila H.

    10. Effects of sodium caprylate on Candida albicans II: influence of various concentrations on biochemical changes. J Bacteriol. 1963;86(3):558–562. Payne WJ, Bannister ER.

    11. Successful treatment of intestinal moniliasis with fatty acid resin complex. Arch Intern Med. 1954;93:53–60. Neuhauser I, Gustus EL.

    12. In vitro killing of Candida albicans by fatty acids and monoglycerides. Antimicrob Agents Chemother. 2001;45(11):3209-12. Bergsson G , Arnfinnsson J, Steingrímsson O , Thormar H.

    13. In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria. J Med Food. 2007 Jun;10(2):384-7. Ogbolu DO. Oni AA, Daini OA, Oloko AP

    14. The fungicidal and fungistatic effects of an aqueous garlic extract on medically important yeast-like fungi. Mycologia.1977;69:341-8. Moore GS, Atkins RD.

    15. Sensitivity of yeasts isolated from cases of vaginitis to aqueous extracts of garlic. Mykosen 1980;23:691-8. Sandhu DK, Warraich MK, Singh S.

    16. Efficacy of garlic (Allium sativum) treatment against experimental candidiasis in chicks. Br Vet J 1980;136:448-51. Prasad G, Sharma VD.

    17. Studies on the anticandidal mode of action of Allium sativum (garlic). J Gen Microbiol. 1988;134:2917-2924. Ghannoum MA.

    18. Antifungal activity in human urine and serum after ingestion of garlic (Allium sativum). Antimicrob Agents Chemother. 1983;23(5):700-702.

    19. The inhibition of Candida albicans by oregano. J Applied Nutr. 1995;47:96–102. Stiles JC, Sparks W, Ronzio RA.

    20. In-vitro activity of essential oils, in particular Melaleuca alternafolia (tea tree) oil and tea tree oil products, against Candida albicans. J Antimicrobial Chemother. 1998;42:591–5. Hammer KA, Carson CF, Riley TV.

    21. In-vitro activity of essential oils, in particular Melaleuca alternafolia (tea tree) oil and tea tree oil products, against Candida albicans. J Antimicrobial Chemother. 1998;42:591–5. Hammer KA, Carson CF, Riley TV.

    22. Efficacy of melaleuca oral solution for the treatment of fluconazole refractory oral candidiasis in AIDS patients. AIDS. 1998;12:1033–7. Jandourek A, Vaishampayan JK, Vazquez JA.