Certain acne antibiotics linked to higher risk of vaginal yeast infections

Certain acne antibiotics linked to higher risk of vaginal yeast infections | Image Credit: © neirfy – stock.adobe.com.

Oral antibiotics frequently prescribed to treat acne, specifically azithromycin and doxycycline, are associated with a significantly increased risk of vulvovaginal candidiasis (VVC), according to a new analysis of electronic medical records presented at the 2025 American College of Obstetricians and Gynecologists (ACOG) Annual Clinical and Scientific Meeting.¹

Researchers examined deidentified data from over 139,000 females diagnosed with acne across 69 US health care organizations using the TriNetX platform. The study assessed the incidence of VVC within 6 months of receiving 4 specific oral antibiotics: doxycycline, minocycline, azithromycin, and erythromycin. These women were compared to a control group of acne patients who had not received any of the 4 antibiotics. Patients with confounding conditions such as pregnancy, diabetes, or HIV/AIDS were excluded to isolate antibiotic-specific risks.

After adjusting for factors such as age, race, and ethnicity using a propensity score model, the researchers found that azithromycin posed the highest risk of post-treatment VVC, with a hazard ratio (HR) of 2.349 (95% CI: 1.928–2.862; P < .0001). Doxycycline was also associated with a statistically significant elevated risk (HR 1.239, 95% CI: 1.129–1.359; P < .0001). Comparatively, azithromycin conferred a 66% greater risk of VVC than doxycycline (HR 1.662, 95% CI: 1.396–1.98; P < .0001).

Meanwhile, minocycline and erythromycin did not show a statistically significant increase in risk. Their hazard ratios were 1.08 (95% CI: 0.908–1.285) and 1.355 (95% CI: 0.814–2.257), respectively.

VVC, commonly caused by Candida albicans, affects up to 75% of women at least once during their lifetime, with 40–45% experiencing more than 1 episode, according to the CDC’s 2021 Sexually Transmitted Infections Treatment Guidelines. While often considered a mild condition, VVC can lead to significant discomfort, including pruritus, burning, abnormal discharge, and painful urination or intercourse. These symptoms, though common, are not specific to VVC and must be confirmed through laboratory testing, such as microscopy or yeast culture.²

In this study, VVC diagnoses were validated not only by ICD coding but also through laboratory confirmation of Candida DNA or RNA in vaginal fluid, increasing the reliability of the findings.¹

Importantly, the CDC notes that VVC is typically not considered a sexually transmitted infection and is usually treated effectively with short-course azole therapies. However, inappropriate or excessive use of antibiotics has long been recognized as a risk factor for fungal overgrowth by disrupting the normal bacterial flora of the vagina, creating an environment conducive to Candidaproliferation.²

The findings from this study suggest that clinicians should be more cautious in their selection of oral antibiotics for acne, particularly in patients with a history of recurrent yeast infections. While azithromycin may be prescribed for its convenience and efficacy in certain cases, its higher risk of triggering VVC warrants consideration of alternative agents like minocycline or erythromycin when appropriate.

For patients who do develop symptoms of VVC following antibiotic treatment, the CDC recommends a range of over-the-counter and prescription therapies, including intravaginal azoles (such as miconazole or clotrimazole) or oral fluconazole, depending on the severity and recurrence of the infection. Most uncomplicated cases respond well to these treatments, but recurrent or complicated VVC may require longer regimens or specialist consultation.²

Ultimately, the authors concluded, “Azithromycin and doxycycline confer a significant risk of developing VVC 6 months post-treatment, with azithromycin conferring the highest risk. This can guide decision making when prescribing oral antibiotics for acne treatment.”

References:

1. Gurram A, Nanduri R, Golvko G, Vincent K. Differential Rates of Vulvovaginal Candidiasis Across Oral Antibiotic Use for Acne Treatment: A Large Database Retrospective Review Using TriNetX. Abstract. Presented at: 2025 American College of Obstetricians and Gynecologists (ACOG) Annual Clinical and Scientific Meeting. May 16-18, 2025. Minneapolis, Minnesota.

2. CDC. Sexually Transmitted Infections Treatment Guidelines 2021, Vuvlvovaginal Candidiasis. CDC. July 22, 2021. Accessed May 15, 2025.