Vulvovaginal candidiasis

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

Symptoms of vulvovaginal candidiasis

According to the estimates, 75% of women will have at least one episode of vulvovaginal candidiasis over a lifetime, and 40-45% have two or more episodes. A small percentage of women (probably less than 5%) develop recurrent vulvovaginal candidiasis (RVVK). Typical symptoms of vulvovaginal candidiasis include itching and vaginal discharge. In addition, there may be soreness in the vagina, irritation in the vulva, dyspareunia and external dysuria. None of these symptoms is specific for vulvovaginal candidiasis.

Diagnosis of vulvovaginal candidiasis

Candidial vaginitis can be suspected in the presence of clinical signs such as pruritus in the vulva, accompanied by erythema in the vagina or vulva; there may be a white highlight. The diagnosis can be made on the basis of signs and symptoms of vaginitis, and also if a) a yeast-like fungus or pseudohyf fungus is found in a wet preparation or a Gram-smeared vaginal discharge, or, if b) culture test or other tests indicate the presence of yeast-like fungi. Candida vaginitis is associated with normal vaginal pH (less than or equal to 4.5). The use of 10% KOH in a moist preparation improves the recognition of yeast and mycelium, since such treatment destroys the cellular material and promotes better visualization of the smear. Identification of Candida in the absence of symptoms is not an indication for treatment, as approximately 10-20% of women Candida and other yeast-like fungi are normal inhabitants of the vagina. Vulvovaginal candidiasis can be found in a woman with other STDs or often occurs after antibiotic therapy.

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

Treatment of Candida vulvovaginitis

Drugs for topical application provide effective treatment of vulvovaginal candidiasis. Local azole drugs are more effective than nystatin. Treatment with azoles leads to the disappearance of symptoms and microbiological cure in 80-90% of cases after completion of therapy.

Recommended regimens for treatment of vulvovaginal candidiasis

The following intravaginal formulations 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 per 3 days **

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

* These creams and suppository have an oily basis and can damage latex condoms and diaphragms. For more information, see the condom annotation.

** Drugs are dispensed without a prescription (OTC).

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

Or Thioconazole 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 per 3 days *.

Oral preparation:

Fluconazole 150 mg - oral tablet, one tablet once.

Intravaginal forms of butoconazole, clotrimazole, miconazole and thioconazole are dispensed without a prescription, and a woman with vulvovaginal candidiasis may choose one of these forms. Duration of treatment with these drugs may be 1, 3 or 7 days. Self-medication with drugs that are dispensed without a prescription is recommended only in cases where a woman has previously been diagnosed with vulvovaginal candidiasis or if such symptoms are seen in relapses. Any woman whose symptoms persist after treatment with over-the-counter drugs, or relapses of symptoms are observed within 2 months, you should seek medical help.

A new classification of vulvovaginal candidiasis can facilitate the selection of antifungal drugs, as well as the duration of treatment. Uncomplicated vulvovaginal candidiasis (from mild to moderate, sporadic, non-recurrent diseases) caused by susceptible strains of C. Albicans) are well treated with azole preparations, even with a short (<7 days) course or with a single dose of drugs.

In contrast, complicated vulvovaginal candidiasis (severe local or recurrent vulvovaginal candidiasis in a patient with physical illnesses, such as uncontrolled diabetes or infection caused by less sensitive fungi, for example C. Glabrata) require a longer (10-14 days) treatment with either local or oral azole preparations. Further studies confirming the correctness of this approach are continuing.

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

Alternative regimens for treatment of vulvovaginal candidiasis

Several trials have shown that some oral azole preparations, such as ketoconazole and itraconazole, can be as effective as topical preparations. The simplicity of using oral medications is their advantage in comparison with topical preparations. However, it should be borne in mind the possible manifestation of toxicity when using systemic drugs, especially ketoconazole.

Follow-up

Patients should be instructed about the need for a repeat visit only if the symptoms do not disappear or recur.

[9], [10], [11]

Management of sexual partners with candidiasis vulvovaginitis

Vulvovaginal candidiasis is not transmitted sexually; treatment of sexual partners is not required, but can be recommended for patients with a recurrent infection. A small number of male sexual partners may have balanitis, characterized by erythematous areas on the glans penis in combination with itching or inflammation; such partners should be treated with the use of local antifungal drugs before the resolution of symptoms.

Special Remarks

Allergy and intolerance to recommended medications

Local remedies usually do not cause systemic side effects, although there may be burning or inflammation. Oral medications sometimes cause nausea, abdominal pain and headaches. Therapy with oral azoles sometimes leads to increased levels of hepatic enzymes. The incidence of hepatotoxicity associated with ketoconazole therapy ranges from 1:10 000 to 1:15 000. There may be reactions associated with simultaneous administration of such drugs as astemizole, calcium channel antagonists, cisapride, coumarin-like agents, cyclosporin A, oral drugs that reduce blood sugar, phenytoin, tacrolim, terfenadine, theophylline, timetrexate and rifampin.

[12], [13], [14]

Pregnancy

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

HIV infection

Current prospective controlled trials confirm the increase in the number of vulvovaginal candidiasis in HIV-infected women. There is no confirmed evidence of a different reaction of HIV-seropositive women with vulvovaginal candidiasis 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 (RVVK), (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, broad-spectrum antibiotics, corticosteroid treatment and HIV infection, although most women with recurrent candidiasis do not have a clear link to these factors. In clinical trials for the management of patients with recurrent vulvovaginal candidiasis, continuous therapy was used between episodes.

Treatment of recurrent vulvovaginal candidiasis

The optimal regimen for the treatment of recurrent vulvovaginal candidiasis has not been established. However, it is recommended to apply the initially intensive scheme within 10-14 days, and then continue supporting treatment for at least 6 months. Ketoconazole, 100 mg perorazno once a day for <6 months reduces the incidence of episodes of recurrent vulvovaginal candidiasis. A recent study evaluated the weekly use of fluconazole. The results obtained showed that, just as with its use once a month or with topical application, fluconazole has only a mild protective effect. All cases of recurrent vulvovaginal candidiasis should be confirmed by a culture method before maintenance therapy is started.

Despite the fact that patients with recurrent vulvovaginal candidiasis should be examined for predisposing risk factors, routine HIV testing for women with recurrent vulvovaginal candidiasis that do not have risk factors for HIV infection is not recommended.

Follow-up

Patients receiving treatment for recurrent vulvovaginal candidiasis should undergo a regular examination to determine the effectiveness of treatment and identify side effects.

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

Management of sexual partners

Treatment of sexual partners by local means can be recommended if they have symptoms of balanitis or dermatitis on the skin of the penis. However, routine treatment of sexual partners is usually not recommended.

HIV infection

There is little data on the optimal management of recurrent vulvovaginal candidiasis in HIV-infected women. While this information is not available, these women should be managed in the same way as women without HIV infection.