Anal Yeast Infection (Perianal Candidiasis): Symptoms, Causes & Treatment

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Estimated reading time: 23 minutes

What Is an Anal Yeast Infection?

An anal yeast infection, also called perianal candidiasis, occurs when Candida yeast causes an infection of the skin around the anus. Candida can live harmlessly on the skin and in other parts of the body, but under certain conditions it can multiply and contribute to inflammation and infection. For a broader overview of Candida, including the different types of yeast infections, see our guide to ⁠Yeast Infections: Causes, Symptoms, Treatment & Natural Support. [4]

The skin around the anus can be particularly vulnerable because it is often warm and exposed to moisture, friction and irritation. Factors such as sweating, prolonged moisture, skin damage, antibiotic use and certain health conditions can make it easier for Candida to cause a problem. [3,4]

A true yeast infection is more than simply finding Candida somewhere in or around the body. Candida can be present without causing disease, so the clinical appearance and symptoms matter when determining whether Candida is actually responsible for the irritation. [4]

This is one reason an itchy or irritated anus should not automatically be labelled a yeast infection. Anal itching (pruritus ani) has many possible causes, including inflammatory skin conditions, hemorrhoids, infections and irritation from products or hygiene practices. [3,5]

When Candida is responsible, the affected skin may become red, inflamed, itchy, burning or sore, and the irritation can sometimes extend beyond the immediate area around the anus. [4]

A useful distinction

It’s helpful to think about three different things:

• Candida colonisation: Candida is present but isn’t necessarily causing symptoms.
• Perianal candidiasis: Candida is contributing to an inflammatory skin infection.
• Anal itching from another cause: The symptoms may look similar but have nothing to do with Candida.

Getting that distinction right matters because treating the wrong cause may not resolve the symptoms.

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Anal Yeast Infection Symptoms

An anal yeast infection can cause itching, burning and irritation around the anus. The symptoms may be mild at first but can become persistent or increasingly uncomfortable as the skin becomes inflamed. [4]

Common symptoms may include:

• Persistent anal itching, sometimes worse at night or after sweating
• Redness or inflammation around the anus
• Burning, stinging or soreness
• Irritated or raw-feeling skin
• A red rash affecting the skin around the anus
• Tenderness or discomfort, particularly when the skin is irritated by wiping or moisture
• Irritation that may extend into the surrounding skin rather than remaining confined to the anal opening [4]

The appearance can vary depending on the person and how long the skin has been irritated. Scratching, repeated wiping and exposure to moisture can further damage the skin and make symptoms more uncomfortable.

What does an anal yeast infection feel like?

For some people, itching is the main symptom. Others may notice more burning, soreness or a feeling that the skin is irritated and unusually sensitive.

However, these symptoms aren’t specific to Candida. Itching, redness and burning can occur with many other conditions, including hemorrhoids, contact dermatitis, eczema, psoriasis and other infections. [3,5]

This means that symptoms can suggest a yeast infection, but they cannot reliably confirm one on their own.

Important: If anal itching or irritation persists, keeps returning, becomes painful, or is accompanied by bleeding, discharge, sores or significant swelling, it is worth having the area assessed rather than repeatedly treating it as a yeast infection.

Can a yeast infection cause anal itching?

Yes. Candida affecting the perianal skin can cause inflammation and itching. But because anal itching has many possible causes, persistent itching shouldn’t automatically be attributed to Candida. [3–5]

That distinction becomes particularly important when trying to decide whether you’re dealing with a yeast infection, hemorrhoids or another skin condition.

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Anal Itching: Is It Yeast or Something Else?

Anal itching is common, but Candida is only one possible cause. The medical term for persistent itching or irritation around the anus is pruritus ani, and there can be several different reasons for it. [3,5]

Sometimes the cause is relatively simple, such as irritation from moisture, sweating, frequent wiping or fragranced soaps and wipes. Other cases may be related to a skin condition, hemorrhoids, infection or another anorectal problem. [3,5]

Causes of anal itching can include:

• Perianal candidiasis — a yeast infection affecting the skin around the anus
• Hemorrhoids — which can cause itching, irritation, discomfort and sometimes bleeding
• Irritant or contact dermatitis — triggered by soaps, wipes, creams, detergents or other products
• Eczema or psoriasis affecting the perianal skin
• Other infections, including bacterial, parasitic or sexually transmitted infections
• Moisture and sweating, particularly when the skin remains damp for prolonged periods
• Excessive cleaning or wiping, which can damage the skin’s protective barrier
• Other anorectal conditions that may require medical assessment [3,5]

This overlap is why symptoms alone aren’t always enough to tell whether Candida is responsible.

A simple clue — but not a diagnosis

If the skin is noticeably red, inflamed and irritated, particularly when there is a rash extending onto the surrounding skin, Candida may be one possibility. [4]

If there is a distinct lump, swelling, bleeding with bowel movements or a feeling of pressure, hemorrhoids may be more likely. However, symptoms can overlap, and having one condition doesn’t necessarily exclude another.

And if the main problem is persistent itching without an obvious rash, there are still many possible explanations.

The takeaway: don’t assume that every itchy anus is a yeast infection. If symptoms don’t settle, keep returning, or aren’t responding to appropriate treatment, finding the underlying cause is more useful than repeatedly treating the symptom. [3,5]

“Anal itching is a symptom, not a diagnosis. Candida is one possibility, but the underlying cause needs to be considered before deciding how to treat it.”

— Eric Bakker, N.D.

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What Causes an Anal Yeast Infection?

Candida normally lives on the body without causing problems. An anal yeast infection can develop when changes in the local environment or other factors allow Candida to multiply and contribute to inflammation of the skin. [4]

The perianal area is particularly susceptible because it can be warm, moist and subject to friction. Skin irritation or damage can also make it easier for infection to develop.

Factors that may increase the likelihood of cutaneous Candida infection include:

Antibiotic use

Antibiotics can alter the balance of microorganisms that normally help keep Candida populations in check. This may increase susceptibility to yeast infections in some people, although not everyone who takes antibiotics develops a Candida infection.

If your symptoms began after taking antibiotics, it’s worth considering Candida as one possibility — but other causes of anal irritation can occur at the same time.

For more about the relationship between antibiotic use, the microbiome and Candida, see our guide to ⁠Can Antibiotics Cause Candida Overgrowth? What You Need to Know

Moisture and sweating

Warm, moist skin provides conditions in which Candida can thrive. Sweating, tight clothing, prolonged dampness and skin-to-skin friction may therefore contribute to irritation and infection. [4]

Skin irritation

Frequent wiping, scratching, harsh soaps, fragranced wipes and other irritants can damage the skin barrier. Once the skin is inflamed or damaged, it may become more susceptible to infection and considerably more uncomfortable.

Diabetes

People with diabetes may be more susceptible to Candida infections, particularly when blood glucose is poorly controlled. [1]

For a broader look at the relationship between blood glucose, Candida and recurrent yeast infections, see our guide to Diabetes and Yeast Infections: Causes, Symptoms & Natural Support.

A weakened immune system

Certain illnesses and medications that affect immune function can increase susceptibility to Candida infections.

Other local or medical factors

Existing skin inflammation, prolonged moisture, occlusion and other conditions affecting the skin can also contribute.

Having one of these risk factors does not mean that Candida is definitely causing your symptoms. It simply makes Candida one of the possibilities to consider alongside other causes of perianal irritation. [3,4]

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Anal Yeast Infection vs Hemorrhoids: How Can You Tell the Difference?

Anal itching can be caused by both perianal candidiasis and hemorrhoids, which can make the two conditions difficult to distinguish based on symptoms alone. They are different conditions, however: a yeast infection involves inflammation or infection of the skin caused by Candida, whereas hemorrhoids are swollen vascular structures in the anal canal or lower rectum. [2,4]

Some symptoms can overlap, but certain features may provide clues.

Anal yeast infection	Hemorrhoids
Itching is often prominent	Itching can occur
Red, inflamed or irritated skin	Swelling or a lump may be noticeable
Burning or stinging	Discomfort or pain, particularly with external hemorrhoids
Rash may affect the surrounding skin	Symptoms may be associated with a bowel movement
Skin may feel raw or sore	Bleeding can occur, particularly with bowel movements
May occur in warm, moist or irritated skin	May be associated with constipation, straining or prolonged time on the toilet

These are general patterns rather than diagnostic rules. Hemorrhoids can cause itching and irritation, while an irritated yeast-infected area can become painful or swollen. It is also possible for someone to have both conditions at the same time.

What does a yeast infection look like compared with hemorrhoids?

A yeast infection tends to affect the skin itself, producing redness, inflammation and irritation. A hemorrhoid, on the other hand, may appear or feel like a swollen lump around the anus, particularly when an external hemorrhoid is present. [2,4]

However, appearances can overlap, and photographs or descriptions found online cannot reliably establish a diagnosis.

What about bleeding?

Bleeding is more characteristic of hemorrhoids than a straightforward skin yeast infection, particularly when bright-red blood occurs during or after a bowel movement. [2]

That doesn’t mean bleeding should simply be assumed to be hemorrhoids. Rectal bleeding has several possible causes, so unexplained, recurrent or significant bleeding should be assessed by a healthcare professional.

Can you have a yeast infection and hemorrhoids at the same time?

Yes. Having hemorrhoids doesn’t prevent Candida from affecting the surrounding skin, and irritation from one condition may make the other more uncomfortable.

This is one reason persistent anal symptoms can be frustrating: treating the suspected yeast infection may not resolve symptoms if hemorrhoids, dermatitis or another condition is also contributing.

If you’re unsure whether you’re dealing with a yeast infection, hemorrhoids or something else, getting the diagnosis right is more useful than repeatedly trying different creams.

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Other Conditions That Can Cause Anal Itching

If you’re experiencing anal itching, Candida isn’t the only possibility. Pruritus ani can have many causes, and more than one factor may sometimes be involved. [3,5]

Other possible causes include:

• Irritant or contact dermatitis from soaps, wipes, creams, detergents or other products
• Eczema or psoriasis
• Hemorrhoids
• Bacterial, parasitic or other infections
• Excessive washing or wiping, which can damage the skin barrier
• Moisture and sweating
• Other anorectal conditions

A prospective study of people with perianal dermatitis found a range of different underlying diagnoses, reinforcing why persistent symptoms shouldn’t automatically be attributed to Candida. [3]

When should you consider something other than yeast?

It’s particularly important to reconsider the diagnosis if:

• symptoms don’t improve with appropriate antifungal treatment
• symptoms keep coming back
• there is significant pain or swelling
• there is bleeding
• you notice sores, ulcers or unusual discharge
• the affected area is spreading or changing
• you aren’t sure what is causing the symptoms

In these situations, a healthcare professional can examine the skin and determine whether further testing or treatment is appropriate.

If you’re experiencing persistent or recurrent symptoms and aren’t sure whether Candida is actually responsible, our guide Candida Testing: How to Test for Candida and Choose the Right Test explains how different tests are used and why the right test depends on the clinical question.

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How Is an Anal Yeast Infection Diagnosed?

An anal yeast infection is usually diagnosed by looking at the affected skin and considering the person’s symptoms, medical history and possible risk factors. The appearance of the rash can provide useful clues, but it may not always be possible to distinguish Candida from other causes of anal irritation by appearance alone. [4]

When the diagnosis is uncertain, a healthcare professional may take a sample of skin or material from the affected area for microscopic examination or other laboratory testing. In perianal candidiasis, examination of skin scrapings with a preparation such as potassium hydroxide (KOH) can help identify fungal elements. [4]

Does finding Candida mean you have an anal yeast infection?

Not necessarily.

Candida can be present on the body without causing disease. Therefore, detecting Candida needs to be interpreted alongside the clinical signs and symptoms rather than automatically being treated as proof that Candida is responsible for the problem. [4]

This is particularly important when symptoms are persistent or recurrent, or when the appearance isn’t typical of a yeast infection.

When might testing be useful?

Testing may be considered when:

• the diagnosis is uncertain
• symptoms don’t respond to appropriate treatment
• symptoms keep returning
• the infection appears unusually extensive or severe
• another skin condition or infection is also possible
• treatment has been unsuccessful and the underlying cause needs clarification

The most appropriate test depends on what question the clinician is trying to answer. There isn’t one Candida test that is appropriate for every situation.

For a broader explanation of the different approaches to Candida testing, see our guide Candida Testing: How to Test for Candida and Choose the Right Test.

Important: If you’ve been treating persistent anal itching as a yeast infection without improvement, don’t simply keep changing antifungal products. The problem may have another cause and may need a different treatment.

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Anal Yeast Infection Treatment

When Candida is responsible for an infection of the perianal skin, treatment generally involves an appropriate antifungal medication. For uncomplicated cutaneous candidiasis, topical antifungal medicines are commonly used, with agents such as clotrimazole, miconazole and nystatin among the best-studied options. [6]

The choice of treatment depends on the location, extent and severity of the infection, as well as whether there are other contributing conditions.

Topical antifungal creams

For a straightforward infection affecting the skin around the anus, a healthcare professional or pharmacist may recommend a topical antifungal.

Commonly used antifungal medicines for cutaneous candidiasis include:

• Clotrimazole
• Miconazole
• Nystatin

Evidence reviews have found these and other topical antifungals to be effective options for cutaneous Candida infections, although the evidence varies between individual treatments and clinical situations. [6]

It’s important to use these products according to their directions and only on the areas for which they are intended. The skin around the anus is sensitive, and some products designed for other parts of the body may not be appropriate for internal use.

What about oral antifungal medication?

Oral antifungal treatment may sometimes be considered when an infection is more extensive, recurrent, difficult to treat or unsuitable for topical treatment. The decision should be made by a healthcare professional because oral antifungals can have drug interactions and other considerations.

For most people with a suspected uncomplicated infection of the perianal skin, there is no reason to assume that stronger or systemic treatment is automatically better.

What if the treatment doesn’t work?

This is an important point.

If symptoms don’t improve with appropriate antifungal treatment, don’t assume that you simply need a stronger antifungal or a longer course.

The original diagnosis may have been incorrect, another condition may be contributing, or there may be more than one problem affecting the area.

That’s when reassessment becomes particularly valuable.

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Caring for Irritated Skin Around the Anus

Whether the irritation is caused by Candida, hemorrhoids, dermatitis or another condition, being gentle with the skin around the anus can help prevent further irritation.

The goal isn’t to scrub the area clean or use lots of products. In fact, excessive washing, wiping and exposure to fragranced products can make already-irritated skin more uncomfortable. [3,5]

Keep the area clean — but don’t over-clean it

Wash gently with lukewarm water and avoid vigorous rubbing. If you use soap, choose a mild, fragrance-free product and rinse it thoroughly.

Avoid repeatedly washing the area throughout the day in an attempt to get rid of the infection. This can damage the skin barrier and potentially make itching and irritation worse.

Keep the area dry

Moisture can contribute to irritation and create an environment in which Candida can thrive. After washing, pat the area dry rather than rubbing it.

If you sweat heavily, changing damp underwear or clothing can also help keep the area more comfortable.

Be careful with wipes and fragranced products

Wet wipes, scented toilet paper, deodorising products, bubble baths and fragranced creams can irritate sensitive perianal skin.

If you’ve developed unexplained itching, consider whether a new soap, wipe, detergent, cream or other personal-care product was introduced around the time your symptoms began.

Try not to scratch

Scratching can create tiny breaks in the skin and perpetuate the itch–scratch cycle. Keeping fingernails short and using gentle measures to reduce irritation can help protect the skin while the underlying cause is being addressed.

Don’t rely on home remedies

Google searches for anal yeast infections can turn up suggestions involving essential oils, vinegar, garlic, baking soda and other household products.

Putting irritating substances on already-inflamed perianal skin isn’t a good way to establish whether Candida is present, and some home remedies can cause chemical irritation or further damage to the skin.

If you think you have an anal yeast infection, it is better to establish the likely cause and use an appropriate treatment rather than experimenting with increasingly strong or irritating substances.

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What If You Have Hemorrhoids and a Yeast Infection at the Same Time?

It is possible to have both.

Hemorrhoids and a perianal yeast infection are different conditions, but they can occur together and produce overlapping symptoms such as itching, irritation and discomfort. [2,4]

For example, someone with hemorrhoids may develop additional irritation of the surrounding skin from moisture, frequent wiping or scratching. If Candida is also contributing to the skin inflammation, treating only the hemorrhoids may not resolve the itching.

Likewise, treating suspected Candida won’t necessarily resolve symptoms caused by hemorrhoids.

Why getting the diagnosis right matters

If you’ve tried an appropriate antifungal treatment and the itching or irritation persists, don’t automatically assume that the Candida is resistant or that you need a stronger treatment.

The symptoms may be coming from:

• hemorrhoids
• dermatitis
• eczema or psoriasis
• another infection
• irritation caused by products or excessive cleaning
• or more than one condition at the same time. [3,5]

Persistent symptoms are a good reason to have the area properly assessed.

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Looking Beyond the Skin: Supporting Gut and Microbiome Health

Treating the affected skin is important when Candida is genuinely responsible for the infection. However, when anal or perianal symptoms keep returning, it can be useful to look beyond the skin itself.

From a naturopathic perspective, recurrent Candida symptoms can be an opportunity to consider the broader factors that influence microbial balance and overall health, including digestive function, diet, bowel regularity, blood sugar regulation, antibiotic exposure, immune health, stress and the gut microbiome.

This doesn’t mean that every perianal yeast infection originates in the gut, or that gut health measures can replace appropriate treatment for a confirmed local infection.

Instead, the aim is to address the immediate problem while also considering why the symptoms may be recurring.

Supporting the Gut Microbiome

The digestive tract contains a complex community of bacteria, fungi and other microorganisms that interact with one another and with the immune system.

Research into the relationship between the gut microbiome, Candida colonisation and recurrent infection is still evolving. While gut-directed approaches cannot be assumed to treat a local perianal Candida infection, supporting general digestive and microbiome health can form part of a broader approach to overall wellbeing.

This may include:

• Eating a varied, fibre-rich diet
• Choosing minimally processed foods most of the time
• Limiting excessive added sugars
• Supporting regular bowel movements
• Staying adequately hydrated
• Avoiding unnecessary antibiotic use
• Getting sufficient sleep
• Managing ongoing stress
• Maintaining healthy blood glucose levels

These measures are not a treatment for an active Candida infection. Rather, they support the broader metabolic, digestive and immune environment in which the body’s microbial communities live.

What If the Symptoms Keep Coming Back?

Recurrent symptoms deserve a closer look.

If itching, redness or irritation repeatedly returns after treatment, it is worth reconsidering whether Candida is definitely responsible. Conditions such as dermatitis, eczema, psoriasis, hemorrhoids, anal fissures and other infections can produce remarkably similar symptoms.

If Candida has been appropriately identified, it may then be useful to consider factors that could be contributing to recurrence, such as:

• Recent or repeated antibiotic use
• Poor blood sugar control
• Digestive disturbances
• Changes in bowel habits
• Ongoing skin irritation or moisture
• Diet and lifestyle factors
• Stress and poor sleep
• Immune health
• Recurrent Candida infections elsewhere in the body

This broader perspective is particularly relevant to naturopathic care, where the focus is not simply on managing the symptom but on identifying and addressing factors that may be contributing to it.

Where Gut Support May Fit

Some people choose to support digestive and microbiome health with probiotics, digestive enzymes or botanical supplements as part of a broader wellness programme.

At Yeastrix, our approach has always been to view these types of supplements as supportive tools rather than replacements for appropriate medical treatment.

For example, a probiotic may be used to support the gut microbiome, while digestive enzymes may support normal digestion. Botanical preparations may also form part of a practitioner-guided programme for people interested in broader digestive and microbial support.

However, there is currently not enough evidence to say that these approaches alone can treat a confirmed perianal Candida infection.

The important distinction is between treating an infection and supporting the underlying terrain in which recurrent problems may occur.

The Bigger Picture

If this is a single episode that resolves with appropriate treatment, there may be little reason to look further.

But if you’re dealing with recurrent symptoms, it may be worth asking:

Why does this keep happening?

Are antibiotics, blood sugar, digestion, bowel health, skin irritation, hormones, stress, immune function or other factors playing a role?

That doesn’t mean every recurrent infection has one hidden cause. Sometimes Candida simply recurs, and sometimes the original diagnosis turns out to have been incorrect.

But looking at the bigger picture can help prevent the cycle of symptom → treatment → recurrence → repeat treatment from continuing indefinitely.

A balanced approach is therefore:

Confirm the cause → treat the infection appropriately → look for contributing factors → support overall health and microbiome balance.

That’s where the naturopathic perspective can sit alongside conventional treatment — rather than competing with it.

When Should You See a Healthcare Professional?

Anal itching is often caused by something relatively minor, but persistent, recurrent or unexplained symptoms deserve attention, particularly when they don’t respond to appropriate treatment. [3,5]

Seek medical advice if you have:

• persistent or worsening itching
• significant pain or swelling
• rectal bleeding, especially if the cause isn’t clear
• discharge or pus
• sores, ulcers or broken skin
• a new or unexplained lump
• symptoms that repeatedly return
• symptoms that don’t improve with appropriate treatment
• an extensive or rapidly spreading rash
• uncertainty about whether the problem is Candida, hemorrhoids or another condition

You should also seek medical advice sooner if you have a condition or take medication that affects your immune system.

Don’t keep treating an uncertain diagnosis

One of the most useful things to remember is that anal itching is a symptom, not a diagnosis.

If an antifungal doesn’t help, that doesn’t necessarily mean you need a different antifungal. It may mean that Candida wasn’t the cause in the first place.

A proper examination can help distinguish between Candida, hemorrhoids, dermatitis, other infections and other causes of perianal symptoms.

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Frequently Asked Questions About Anal Yeast Infections

The Bottom Line

An anal yeast infection is a real form of Candida infection, and it can cause significant itching, burning, redness and irritation around the anus. [4]

But Candida isn’t the only explanation for these symptoms. Hemorrhoids, dermatitis, eczema, psoriasis, other infections and simple irritation can look or feel remarkably similar. [3,5]

If symptoms are persistent, recurrent or don’t improve with appropriate treatment, getting the diagnosis right is more important than simply trying another cream.

Understanding what is actually causing the irritation is the first step towards choosing the right treatment.

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References

1. Cornely, O. A., Sprute, R., Bassetti, M., Chen, S. C.-A., Groll, A. H., Kurzai, O., Lass-Flörl, C., Ostrosky-Zeichner, L., Rautemaa-Richardson, R., Revathi, G., Santolaya, M. E., White, P. L., Alastruey-Izquierdo, A., Arendrup, M. C., Baddley, J., Barac, A., Ben-Ami, R., Brink, A. J., … Zhu, L.-P. (2025). Global guideline for the diagnosis and management of candidiasis: An initiative of the ECMM in cooperation with ISHAM and ASM. The Lancet Infectious Diseases, 25(5), e280–e293. https://doi.org/10.1016/S1473-3099(24)00749-7

2. Hawkins, A. T., Davis, B. R., Bhama, A. R., Fang, S. H., Dawes, A. J., Feingold, D. L., Lightner, A. L., & Paquette, I. M. (2024). The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the management of hemorrhoids. Diseases of the Colon & Rectum, 67(5), 614–623. https://doi.org/10.1097/DCR.0000000000003276

3. Kränke, B., Trummer, M., Brabek, E., Komericki, P., Turek, T. D., & Aberer, W. (2006). Etiologic and causative factors in perianal dermatitis: Results of a prospective study in 126 patients. Wiener Klinische Wochenschrift, 118(3–4), 90–94. https://doi.org/10.1007/s00508-006-0529-x

4. McGirt, L. Y., & Martins, C. R. (2004). Dermatologic diagnoses in the perianal area. Clinics in Colon and Rectal Surgery, 17(4), 241–245. https://doi.org/10.1055/s-2004-836945

5. Newman, M., Maun, D., & Dolejs, S. (2026). Pruritis ani. Surgical Clinics of North America, 106(1), 23–34. https://doi.org/10.1016/j.suc.2025.08.006

6. Taudorf, E. H., Jemec, G. B. E., Hay, R. J., & Saunte, D. M. L. (2019). Cutaneous candidiasis: An evidence-based review of topical and systemic treatments to inform clinical practice. Journal of the European Academy of Dermatology and Venereology, 33(10), 1863–1873. https://doi.org/10.1111/jdv.15782

Continue Reading

• Yeast Infections: Causes, Symptoms, Treatment & Natural Support
• Can Antibiotics Cause Candida Overgrowth? What You Need to Know
• Candida Testing: How to Test for Candida and Choose the Right Test
• Candida Treatment Yeast Infection: What Actually Works (And What Doesn’t)
• Male Yeast Infection vs Jock Itch: Key Differences

Disclaimer: This article is for general educational purposes only and does not replace medical advice, diagnosis or treatment from a qualified healthcare professional. Persistent, recurrent, painful or unexplained symptoms should be properly assessed before treatment.