Vulvovaginal candidiasis

Vulvovaginal candidiasis is caused by Candida albicans and sometimes other Candida species, Tomlopsis or other yeast-like fungi.

Symptoms of vulvovaginal candidiasis

It is estimated that 75% of women will have at least one episode of vulvovaginal candidiasis during their lifetime, and 40-45% will have two or more episodes. A small percentage of women (probably less than 5%) will develop recurrent vulvovaginal candidiasis (RVVC). Typical symptoms of vulvovaginal candidiasis include vaginal itching and discharge. Other symptoms may include vaginal soreness, vulvar irritation, dyspareunia, and external dysuria. None of these symptoms are specific for vulvovaginal candidiasis.

Diagnosis of vulvovaginal candidiasis

Candidal vaginitis is suspected in the presence of clinical features such as vulvar pruritus accompanied by vaginal or vulvar erythema; a white discharge may be present. The diagnosis is made based on the signs and symptoms of vaginitis and if a) yeasts or pseudohyphae are found on wet mount or Gram stain of vaginal discharge or b) culture or other tests indicate the presence of yeasts. Candidal vaginitis is associated with normal vaginal pH (less than or equal to 4.5). The use of 10% KOH in the wet mount improves the detection of yeasts and mycelium because it disrupts the cellular material and allows better visualization of the smear. Identification of Candida in the absence of symptoms is not an indication for treatment, since Candida and other yeast-like fungi are normal inhabitants of the vagina in approximately 10-20% of women. Vulvovaginal candidiasis may be detected in a woman along with other STIs or often occurs after antibiotic therapy.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Treatment of candidal vulvovaginitis

Topical preparations provide effective treatment for vulvovaginal candidiasis. Topically applied azole preparations are more effective than nystatin. Treatment with azoles results in symptom resolution and microbiological cure in 80-90% of cases after completion of therapy.

Recommended treatment regimens for candidal vulvovaginitis

The following intravaginal forms of drugs are recommended for the treatment of vulvovaginal candidiasis:

Butoconazole 2% cream, 5 g intravaginally for 3 days**

Or Clotrimazole 1% cream, 5 g intravaginally for 7-14 days**

Or Clotrimazole 100 mg vaginal tablet for 7 days*

Or Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days*

Or Clotrimazole 500 mg 1 vaginal tablet once*

Or Miconazole 2% cream, 5 g intravaginally for 7 days**

Or Miconazole 200 mg vaginal suppositories, 1 suppository for 3 days**

Or Miconazole 100 mg vaginal suppositories, 1 suppository for 7 days**

*These creams and suppositories are oil-based and may damage latex condoms and diaphragms. For more information, see the condom label.

**The drugs are available without a prescription (OTC).

Or Nystatin 100,000 IU, vaginal tablet, 1 tablet for 14 days

Or Tioconazole 6.5% ointment, 5 g intravaginally once**

Or Terconazole 0.4% cream, 5 g intravaginally for 7 days*

Or Terconazole 0.8% cream, 5 g intravaginally for 3 days*

Or Terconazole 80 mg suppositories, 1 suppository for 3 days*.

Oral preparation:

Fluconazole 150 mg - oral tablet, one tablet once.

Intravaginal forms of butoconazole, clotrimazole, miconazole, and tioconazole are available over the counter, and a woman with vulvovaginal candidiasis may choose one of these forms. The duration of treatment with these drugs may be 1, 3, or 7 days. Self-medication with over-the-counter medications is recommended only if a woman has previously been diagnosed with vulvovaginal candidiasis or has symptoms that recur. Any woman whose symptoms persist after treatment with over-the-counter medications, or whose symptoms recur within 2 months, should seek medical advice.

A new classification of vulvovaginal candidiasis may facilitate the choice of antifungal agents and the duration of treatment. Uncomplicated vulvovaginal candidiasis (mild to moderate, sporadic, non-recurrent infections) caused by susceptible strains of C. albicans responds well to azole drugs, even with a short (< 7 days) course or when using a single dose of drugs.

In contrast, complicated vulvovaginal candidiasis (severe local or recurrent vulvovaginal candidiasis in a patient with underlying medical conditions such as uncontrolled diabetes or infection with less susceptible fungi such as C. glabrata) requires longer (10-14 days) treatment with either topical or oral azole preparations. Additional studies are ongoing to support the validity of this approach.

[ 5 ], [ 6 ], [ 7 ], [ 8 ]

Alternative treatment regimens for vulvovaginal candidiasis

Several trials have shown that some oral azole drugs, such as ketoconazole and itraconazole, may be as effective as topical preparations. The ease of use of oral preparations is an advantage over topical preparations. However, the potential for toxicity with systemic preparations, especially ketoconazole, must be kept in mind.

Follow-up observation

Patients should be instructed to return for a follow-up visit only if symptoms persist or recur.

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Management of sexual partners with candidal vulvovaginitis

Vulvovaginal candidiasis is not sexually transmitted; treatment of sexual partners is not required but may be recommended for patients with recurrent infection. A small number of male sexual partners may develop balanitis, characterized by erythematous areas on the glans penis with pruritus or inflammation; such partners should be treated with topical antifungals until symptoms resolve.

Special Notes

Allergy and intolerance to recommended drugs

Topical agents generally do not cause systemic side effects, although burning or inflammation may occur. Oral agents occasionally cause nausea, abdominal pain, and headache. Oral azole therapy occasionally results in elevated liver enzymes. The incidence of hepatotoxicity associated with ketoconazole therapy ranges from 1:10,000 to 1:15,000. Reactions associated with concomitant administration of drugs such as astemizole, calcium channel blockers, cisapride, coumarin-like agents, cyclosporine A, oral hypoglycemic agents, phenytoin, tacrolimus, terfenadine, theophylline, timetrexate, and rifampin may occur.

[ 12 ], [ 13 ], [ 14 ]

Pregnancy

VVC is often observed in pregnant women. Only topical azole preparations can be used for treatment. The most effective drugs for pregnant women are: clotrimazole, miconazole, butoconazole, and terconazole. During pregnancy, most experts recommend a 7-day course of therapy.

HIV infection

Current prospective controlled studies confirm an increased incidence of vulvovaginal candidiasis in HIV-infected women. There is no evidence that HIV-seropositive women with vulvovaginal candidiasis respond differently to appropriate antifungal therapy. Therefore, women with HIV infection and acute candidiasis should be treated in the same way as women without HIV infection.

Recurrent vulvovaginal candidiasis

Recurrent vulvovaginal candidiasis (RVVC), four or more episodes of vulvovaginal candidiasis per year, affects less than 5% of women. The pathogenesis of recurrent vulvovaginal candidiasis is poorly understood. Risk factors include diabetes, immunosuppression, treatment with broad-spectrum antibiotics, treatment with corticosteroids, and HIV infection, although in most women with recurrent candidiasis the association with these factors is not clear. Clinical trials of the management of recurrent vulvovaginal candidiasis have used continuous therapy between episodes.

Treatment of recurrent vulvovaginal candidiasis

The optimal regimen for the treatment of recurrent vulvovaginal candidiasis has not been established. However, an initial intensive regimen for 10–14 days followed by maintenance therapy for at least 6 months is recommended. Ketoconazole 100 mg orally once daily for < 6 months reduces the incidence of recurrent vulvovaginal candidiasis. A recent study evaluated weekly fluconazole and found that, as with monthly or topical use, fluconazole had only a modest protective effect. All cases of recurrent vulvovaginal candidiasis should be confirmed by culture before maintenance therapy is initiated.

Although patients with recurrent vulvovaginal candidiasis should be evaluated for predisposing risk factors, routine testing for HIV infection in women with recurrent vulvovaginal candidiasis who do not have risk factors for HIV infection is not recommended.

Follow-up observation

Patients receiving treatment for recurrent vulvovaginal candidiasis should be monitored regularly to determine the effectiveness of treatment and to detect side effects.

[ 15 ], [ 16 ], [ 17 ], [ 18 ], [ 19 ]

Management of sexual partners

Topical treatment of sexual partners may be recommended if they have symptoms of balanitis or dermatitis on the skin of the penis. However, routine treatment of sexual partners is not generally recommended.

HIV infection

There are few data regarding the optimal management of recurrent vulvovaginal candidiasis in HIV-infected women. Until this information is available, these women should be managed as women without HIV infection.