This article is published at The Environmental Illness Resource (EiR) website.
A small intestinal candida/yeast overgrowth is a common finding amongst environmental illness patients according to lab tests such as the organic acid urinary analysis and gut fermentation profiles, as well as patient repsonses to Dr. William Crook’s yeast questionnaire. As a result, anti-fungal therapy is usually a major part of an overall functional/integrative medicine based treatment plan for these illnesses. This is usually made up of three distinct parts, an anti-fungal diet, anti-fungal medications and/or natural products and finally, probiotic supplementation. Most people seem to get the best benefit when treatment involves all three parts, implemented properly at the same time, as they work together to restore the normal balance of organisms in the small intestine. If anti-fungal agents were taken without concurrent probiotic supplementation for example, with the amount of yeast reduced and no supply of beneficial bacteria to replace it, the opportunity is there for pathogenic bacteria to become dominant.
The Anti-Fungal Diet
First outlined by Dr. William Crook in his book ‘The Yeast Connection’, the anti-fungal diet has been an integral part of treating intestinal yeast overgrowth ever since. The aim of the diet is to reduce intake of sugar and refined carbohydrates as well as moldy foods and yeast products. The reason for reducing sugar and refined carbohydrate intake is that yeast feed on sugar and ferment it producing alcohol in the form of ethanol (drinking alcohol) and an even more toxic chemical called acetaldehyde. By reducing the amount of sugar in your diet you are also reducing the amount available to the yeast in your intestines. This may help to keep their growth in check and will also reduce the amount of toxic waste products they create as a result of fermentation. Elimination of moldy foods and yeast products is suggested because as a result of an intestinal yeast overgrowth the likelihood of developing an immune reactions to these things is greatly increased. This is as a result of yeast overgrowth leading to leaky gut syndrome and the possibility of “translocation” of the organisms from the intestine into the blood stream and other body tissues where they may cause immune reactions, mainly of the IgG mediated delayed reaction type. As a result, the immune system may cross react with molds and yeasts from your diet.
A typical anti-fungal diet has the following restrictions:
Foods that must be avoided are:
Sugar & sugar containing foods:
Table sugar (Sucrose) and all other simple, fast releasing sugars such as fructose, lactose, maltose, glucose, mannitol and sorbitol. All honey and sugar syrup type products such as maple syrup and molasses.
Packaged and processed foods:
This includes canned, bottled, boxed and otherwise processed and pre-packaged foods as they more often than not contain sugar of one type or another.
Canned – Baked beans, soups, ready-made sauces
Bottled – Soft drinks, fruit juices, condiments/sauces
Boxed/Packaged – Ready-made meals, breakfast cereals, chocolate/candy, ice cream, frozen foods.
Mold and yeast containing foods:
Cheeses: moldy cheeses like stilton are the worst, buttermilk, sour cream and sour milk products.
Alcoholic drinks: beer, wine, cider, whiskey, brandy, gin and rum.
Condiments: vinegar and vinegar containing foods like mayonnaise, pickles, soy sauce, mustard and relishes.
Malt products: cereals, candy and malted milk drinks.
Edible fungi: including all types of mushrooms and truffles.
Processed and smoked meats: sausages, hot dogs, corned beef, pastrami, smoked fish, ham, bacon.
Fruit juices: All packaged fruit juices may potentially contain molds. Fresh fruit juices are allowed in moderation due to their sugar content.
Dried fruits: raisins, apricots, prunes, figs, dates etc.
Foods to be eaten in moderation
Grains: Wheat, rice, corn, barley, millet, oats.
High carbohydrate vegetables: sweet corn, potatoes, beans and peas, sweet potatoes, squashes, turnips, parsnips.
Anti-fungal drugs and natural products
For mild cases the diet along with healthier lifestyle choices in general may be enough to resolve the problem, however in moderate to severe problems an anti-fungal drug or a natural product with anti-fungal activity will need to be taken as well. The question of whether to use a drug or a natural product is one for you and your doctor to decide upon. From personal reports and the limited scientific evidence that is available, a lot of the natural products do seem to be as effective as many of the anti-fungal drugs. The exception maybe the systemic drugs which are usually reserved for cases that won’t respond to either drugs that only act in the intestine, such as Nystatin, or the natural anti-fungal’s. Most doctors treating yeast overgrowth suggest that patients will need to take the majority of anti-fungal’s for at least 3 months and some will have to stay on them indefinitely. Of course most will be somewhere in between these extremes. Below we’ll take a look at the most common anti-fungal’s. and the advantages and disadvantages of each. It should be noted here that with any anti-fungal treatment there is a chance of experiencing what is known as the Herxheimer or “die-off” reaction. This is said to occur as a result of the yeast being killed too rapidly which overwhelms the body with yeast cells and their toxins. Any number of nasty symptoms can arise as a result, most frequently a flu-like feeling or worsening of symptoms already present. The solution to this may be to take a lower dose of anti-fungal for a while or take extra fibre or a product like bentonite clay to help carry the toxins out of the body before they are absorbed.
Nystatin was one of the first anti-fungal drugs developed and probably the most commonly used to treat intestinal yeast overgrowth. It is extremely safe due to the fact that hardly any of the drug is absorbed from the intestinal tract. As a result the only side-effects that may occur are mainly restricted to the digestive system and are usually mild. In addition, in rare cases patients may develop a rash as a result of an allergic reaction. Nystatin is available in a number of different forms including, tablets, powder and liquid oral suspension. You can therefore choose the form that suits you best. The liquid and powder forms are probably superior to tablets because they don’t need to be digested before they start to work and hence will kill yeast further up the digestive tract. The only drawback to this is the extremely foul taste! The usual dosage of nystatin ranges from 1 tablet or 1/8 of a teaspoon of powder 4 times a day to 8 tablets or 1 teaspoon 4 times a day. Another advantage of this drug is that it is very cheap compared to all of the others. As a result of it being cheap, safe and relatively effective, nystatin is likely to be the first choice treatment for many people and their doctors. The only drawback is that due to its widespread use for decades certain yeast species are becoming resistant to it.
This drug is similar to nystatin as it is chemically related. As with nystatin it is not absorbed from the intestine in any significant amount so again is very safe. You may hear stories of amphotericin being very toxic or poisonous but don’t worry, this is most likely referring to IV use of the drug in hospitalized patients suffering a fungal infection of the blood or severe infection of body tissues. This doesn’t apply to its use in the digestive tract. Amphotericin B may be effective in cases where nystatin has failed so it is something to consider if that is the case with you. The drawback of this drug is the cost, it is significantly more expensive that nystatin and therefore is rarely used as a first line treatment unless a sensitivity test has indicated it to be the most effective in a particular patient.
Diflucan belongs to a group of drugs called the ‘azoles’ and unlike the previous two drugs, Diflucan is absorbed by the intestines and is referred to as a systemic anti-fungal drug. Diflucan is a more modern drug than nystatin and amphotericin, it was first used in Europe during the 1980’s and licensed in the US in 1990. A lot of doctors and patients have found Diflucan (and other azoles) to be effective where nystatin and amphotericin have failed. It has been found to be very safe considering its systemic action with few side-effects reported by patients. The dosage range is typically from 100 to 600mg a day with period of treatments ranging from a few weeks to many months or in rare cases, indefinitely. Treatment with Diflucan is certainly not cheap, current prices are typically $150-$200 for 30 100mg tablets. With some patients needing up to 600mg or more a day the price will put it out of reach for many if insurance won’t pay for it. These prices were from a major online pharmacy, if you shop around you will likely find significantly cheaper sources.
Sporanox is one of the newest azole drugs being licensed in the US in 1993. It would seem to be similar in safety and effectiveness as Diflucan but may be a more successful treatment for certain species of candida and other fungal infections as Diflucan may be more effective for other species. Unless you have a stool sample tested and a particular species of candida/yeast can be detected and tested for sensitivity to different drugs, it is a matter of trial and error with regards to which will work best for you. Dosages are typically 100 to 400mg a day and prices are comparable to Diflucan, possibly being slightly more.
This drug was the first of the azole drugs to be developed but its use is limited due to the possibility of serious liver damage. As a result, patients must undergo regular liver enzyme tests during treatment to monitor the effects. In cases that have failed to respond to any other anti-fungal agent its use may be justified but otherwise it is probably best avoided.
Lamisil (Terbinafine HCL)
This is the newest anti-fungal drug in routine use. It is a systemic drug but is unrelated to the other systemic ‘azole’ drugs. As a result it is an effective treatment as yeast have not yet had chance to develop resistance to it. Lamisil has become more and more widely used since its introduction a few years ago and is set to become the systemic drug of choice, replacing Diflucan. As with most of the systemic drugs there have been instances of adverse effects on the liver and as with Sporanox, Lamisil has recently been linked with congestive heart failure. Lamisil is marginally more expensive than Diflucan and Sporanox with 30 250mg tablets costing between $200 and $250.
Saturated Fatty Acids
Undecylenic and caprylic acids are common medium chain saturated fatty acids used to treat yeast infections. Both are found naturally in the human body in small amounts. Common commercial sources of caprylic acid are palm and coconut oils, whereas undecylenic acid is extracted from castor bean oil. Caprylic acid products are far more common than those of undecylenic acid but don’t assume this means it is better, undecylenic acid has far more research data avilable on it and was the treatment of choice for fungal skin infections for a long time before newer drugs arrived1,2. Both have been shown to be comparable to a number of common anti-fungal drugs. In fact undecylenic acid was the main agent used to treat fungal infections prior to the development of newer drugs and is still prescribed today for some infections. A typical dosage for caprylic acid would be up to 3600mg per day in divided doses with meals. Undecylenic acid is commonly taken in dosages of up to 1000mg per day, again in divided doses. A major advantage of using natural products over drugs is the cost. A months supply of either of these fatty acids will cost only about $20-30 for a quality product.
Berberine is an alkaloid found in a herb called barberry (Berberis vulgaris) and related plants as well as in goldenseal, oregon grape root and Chinese goldthread. This herb has long been used in chinese and ayurvedic medicine. Berberine has significant anti-fungal activity and is also effective against some kinds of bacteria. As with all previously covered anti-fungal’s, berberine is reported to spare beneficial organisms such as lactobacilli species. An added benefit for some people is its anti-diarrheal action. Research has shown that berberine can effectively prevent candida species from producing an enzyme called lipase which they use to help them colonize3. Berberine has also been widely shown to have a powerful directly anti-fungal action4,5 Cost of treatment with berberine is roughly equivalent to that of the fatty acids.
Most people will be familiar with oregano as the strong smelling herb commonly used as a seasoning in Italian food. This is usually Oregano marjoram rather than Oregano vulgare that we’re interested in here. Oregano vulgare contains a variety of substances that make it an effective anti-fungal. In a study assessing its action against Candida albicans, carvacrol, a major phenolic constituent of the oil, was found to inhibit candida to a greater extent than caprylic acid. It is also highly effective against many bacteria with studies published in the most prestigious medical journals showing it is as effective as many antibiotic drugs. Usually supplied in oil form, oregano treatment will cost around $25 per month. It is very potent so only a few drops in a glass of water are needed at a time. Higher dosages would be likely to cause irritation of the mucous membranes.
Garlic (Allium sativum) contains a large number of sulphur containing compounds that exhibit potent anti-fungal properties. Among the most studied are allicin, alliin, alliinase and S-allylcysteine. Some studies have found garlic to be at least as effective as nystatin at killing Candida albicans. A point that should not be overlooked is that because of the many different compounds with anti-fungal properties in garlic, yeast and fungi are unlikely to become resistant to it. Garlic also has many other beneficial properties particularly for the cardiovascular system. It has been shown to lower levels of LDL cholesterol and act as an anti-coagulant, lowering blood pressure as a result. Like barberry, garlic has a long history of medicinal use, reportedly dating back as far as 3000 years. For treating intestinal yeast infections garlic is available in a number of different forms including, odorless capsules, liquid extract and tablets. However, a study at the National Institutes of Health found that fresh garlic was significantly more potent against Candida albicans. It also found that the fresh garlic could be a suitable alternative to drugs for serious systemic infections in patients with severe immune suppression. Therefore adding garlic to food (raw) or crushing and swallowing raw cloves if you can tolerate it, is a cheap and powerful anti-fungal treatment.
A colloid is defined as very small particles of one substance suspended (not dissolved) in another. Colloidal silver is a suspension of silver particles in water. Silver is a well known anti-microbial, it is commonly used in items such as water filters to kill any microbe that may be in the water, including bacteria, fungi, worms and protozoa. Colloidal silver is said to be effective against up to 650 pathogens including, of most interest to us here, yeast and fungi species including Candida. It works by denaturing the enzyme involved with supplying the organism with oxygen. Chances of resistance to this process are by all accounts, very low. It was used widely to treat infection before the development of antibiotic drugs. It is now classified as a pre-1938 drug by the FDA which means that it is available without prescription. The number of companies offering colloidal silver as an alternative to antibiotic medications is increasing daily. The renewed interest can be explained by the increase in chronic infections and the fact that many microbes are becoming resistant to the commonly used drug treatments. The dosage of colloidal silver needed to treat yeast overgrowth will vary between products because they may have slightly different concentrations. Prices are similar to the other natural products discussed at about $30 for an 8oz bottle.
This is a relatively new treatment approach for intestinal yeast infections. The cell wall of common intestinal yeast such as Candida species have been found to be made mainly from cellulose. Cellulase is the enzyme that breaks down cellulose and hence, when significant concentrations come into contact with yeast cells the cell wall is irreparably damaged and the organism dies. It’s claimed that using this mode of action, the yeast do not release a flood of toxins when they die as occurs with most other anti-fungal agents so that the sufferer does not experience the usual die-off symptoms to any significant degree. The yeast should be unable to develop resistance to cellulase products as they lack the ability to modify their cell wall. As cellulase products have only been around for a few years reports of their effectiveness in practice is limited but they offer a promising alternative to more established treatments. Prices again, are in a similar range to all the natural anti-fungal’s.
Tannins are natural substances found in a number of plants such as Black Walnut and a vast array of plants used in traditional eastern medicine. Tannins are what give red wines such as merlots and cabernets their sharp, biting taste. They are also found in the bark of trees that are particularly resistant to fungus such as the redwood tree. They have been demonstarted to have a powerful anti-fungal and astringent action in a multitude of clinical studies6,7,8. Tannins are one of a number of natural substances tested against pathogens found in stool samples by functional medicine labs. More information can be found on these tests here. Tannins are available in a number of froms to treat intestinal yeast overgrowth. As previously mentioned they are the active anti-fungal ingredient in many traditional eastern herbal preperations. Black walnut has a very high tannin content and is commonly used to treat infections with Candida sp, parasites and worms. It is widely available from health stores and nutritional supplement suppliers. Tannins are also available in an isolated and concentrated form. Treatment with plant tannins is comparable in cost to most natural anti-fungal agents, being in the region of $15-$30 per month.
It is essential that as the yeast overgrowth is being treated probiotic bacteria are consumed to take the place of the yeast colonies. To learn more about probiotics click here