OVERVIEW: What every practitioner needs to know about Candida vulvovaginitis

Are you sure your patient has Candida vulvovaginitis? What should you expect to find?

  • Symptoms of Candida vaginitis include



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    in more severe cases, burning on micturition.

    because of the accompanying inflammation, intercourse would be uncomfortable or painful

  • Symptoms vary in severity and intensity from mild to severe

  • Physical findings confirm the presence of vulvitis in addition to vaginitis.

  • One can anticipate erythema, edema or excoriation and sometimes fissures in the vulva and perineum.

  • Entrance to the vagina (the vestibule) will be erythematous and the labia swollen.

  • The vagina usually contains an abnormal discharge, but not always. The vagina tends to be erythematous and the discharge varies from classic curd-like, cottage cheese like, but may occur as white and watery and nonspecific.

  • You cannot look at a patient and confidently diagnose Candida vaginitis. Every patient needs laboratory confirmation.

  • Self-diagnosis by patients who claim to have recurrent infections is unreliable.

Which individuals are of greater risk of developing Candida vulvovaginitis?

  • Candida vulvovaginitis does not occur before puberty due to the need for the presence of estrogen to create conditions suitable for Candida virulence expression

  • Candida vulvovaginitis frequency peaks during the second and third decade accompanying onset of sexual activity.

  • In general, Candida vulvovaginitis is far less common in post- menopausal women unless they continue to use estrogen replacement therapy especially with topical estrogen.

  • Candida vulvovaginitis effects all strata of society, and is not considered a sexually transmitted infection

  • Underlying local causes may predispose to recurrent disease

    Uncontrolled diabetes mellitus especially type II

    Associated vulvar dermatological conditions such as

    lichen sclerosus

  • The use of topical corticosteroid predisposes to Candida infection.

  • Recurrent Candida vulvovaginitis has recently been associated with Chronic Mucocutaneous Candidiasis (CMC) a rare familial syndrome,

    Several possible genetic factors contribute to idiopathic recurrent Candida vaginitis in otherwise healthy women who never developed cutaneous or oral candidiasis.

    As yet, the genetic information has not translated into any therapeutic measures.

Beware: there are other diseases that can mimic Candida vulvovaginitis:

  • Remember that bacterial vaginosis and trichomoniasis always result in an elevated pH and BV does not result in vulvitis

  • Most patients with symptoms suggestive of yeast, with negative tests and a normal pH represent a non-infectious form of vulvovaginitis, which includes

    contact dermatitis

    a variety of dermatoses

What laboratory studies should you order and what should you expect to find?

Results consistent with the diagnosis

  • Vaginal pH will be found to be normal, i.e. less than 4.5 (4 – 4.5)

  • Saline and 10% KOH microscopy:

    Time consuming

    Relatively low sensitivity especially for practitioners not performing these tests on a regular basis

Results that confirm the diagnosis

  • Candida culture by simply sending off a dry swab placed in transport media.

    Culture results will be available within 48 hours.

    Since 90% of patients or more of Candida vulvovaginitis are caused by Candida albicans, it is not essential to obtain the species in all patients

    Patients with refractory disease, chronic and recurrent disease, species should be defined so as to prioritize your treatment options.

  • Alternatively an AFIRM Test® can be obtained

    Reliable results within a matter of hours.

  • PCR testing is now available

    usually not point of care and results available within 2-3 days.

What imaging studies will be helpful in making or excluding the diagnosis of Candida vulvovaginitis?

  • Imaging studies are not needed for the diagnosis of Candida vulvovaginitis

What consult service or services would be helpful for making the diagnosis and assisting with treatment?

This infection can usually be managed by primary care physicians unless the patient is suffering from recurrent disease. Under these circumstances a gynecologist should be consulted.

If you decide the patient has candida vulvovaginitis, what therapies should you initiate?
Key principles of therapy

Management consists of either oral or topical therapeutic options.

  • In women with sporadic, occasional episodes, treat with single dose oral fluconazole 150 mg or a variety of topical agents.

  • For mild to moderate disease, short course topical therapy is highly effective and single dose or treatment for a few days is all that is necessary.

  • A list of topical agents is available in the accompanying Table I.

  • Individual episodes of Candida vulvovaginitis caused by C. albicans respond well to short-duration oral or topical azole therapy.

  • A longer duration of therapy (e.g., 7–14 days of topical therapy or a 100mg, 150mg, or 200mg oral dose of fluconazole every third day for a total of 3 doses [day 1, 4, and 7]) should be considered for diabetic patients with poor glucose control.

  • In patients with severe disease or recurrent disease, short course therapy will be inadequate.

    Topical therapy for seven days will be necessary.

    If fluconazole is used, a second tablet of fluconazole can be given 72 hours after the first in order to achieve therapeutic concentrations in the vagina for as long as a week. A single tablet would prove inadequate

  • Similarly, long course therapy is recommended in pregnancy.

Table I.n

Recommended Treatment Regimens for VVC in Diabetic Women

How should I manage recurrent Candida vulvo-vaginitis?
  • After excluding any obvious predisposing factors which are rarely found, the patient should be reassured that they can be placed onto maintenance regimens that are highly efficient in preventing recurrent disease.

    There is no single magic bullet; however, after inducing remission

    Once weekly fluconazole at a dose of 150mg per week will provide a greater than 90% control of the process and allow the patient to enjoy an asymptomatic life including normal sexual activity.

    Fluconazole is recommended for a period of six months and without the need to perform any liver function tests.

    Side effects are extremely rare with long term fluconazole but include

    Occasional rashes and gastrointestinal disturbances.

    Liver function tests are unnecessary.

    Rare complications include allergic reaction such as Steven Johnson syndrome

    Hair loss may occur but is uncommon.

    After six months the fluconazole should be withdrawn.

    In approximately 50%, the patient will remain asymptomatic in full remission.

    The other 50% will have a recurrence of genital symptoms and an acute Candida vaginitis episode will occur and usually does so within two to three months.

    It is impossible to predict which patients will go into long term remission and who will recur.

    Following a rapid recurrence, and following a pattern of three or four attacks per year, patients should be offered the opportunity of going on to fluconazole maintenance therapy for one year or longer.

    Long term adverse effects are rare and rarely fluconazole resistance is reported.

How should I manage recurrent disease associated with the less common Candida species?
  • Non-albicans Candida species including tropicalis, parapsilosis and glabrata are responsible for up to 10% of episodes.

    With the exception of glabrata, and krusei, the other species will respond well to fluconazole therapy

    C. krusei usually responds to other conventional azoles.

    C. glabrata is frequently resistant to all azoles both topical and oral.

    intravaginal boric acid, 600 mg at night for 14 days cures approximately 70% of patients

    Nystatin suppository 100,000 units daily should be administered if boric acid fails.

What complications could arise as a consequence of Candida vulvovaginitis?

  • Recurrent disease is the major complication associated with Candida vulvovaginitis

    About 5-9% of the population of women in their reproductive age will report recurrent bouts of Candida vaginitis.

    In only a minority will a local cause be found such as uncontrolled diabetes or local dermatologic entities.

    In the majority of patients, no local or systemic cause is apparent.

  • In the past, it was recommended that women with recurrent disease undergo testing to exclude diabetes mellitus or HIV.

    However, diabetes unlikely to present as recurrent vaginitis as its only manifestation and certainly glucose tolerance tests are now unnecessary.

    Recurrent Candida vaginitis is rarely, if ever, the only manifestation of unrecognized HIV infection

    if the patient has participated in high risk behavior and has other factors that put her at risk of HIV, especially in the presence of systemic manifestations then HIV testing is reasonable.

    HIV testing should not be routinely performed in women with recurrent Candida vaginitis.

WHAT'S THE EVIDENCE for specific management and treatment recommendations?

Anderson, MR, Klink, K, Cohrssen, A. “Evaluation of vaginal complaints”. JAMA. vol. 17. 2004. pp. 1368-79. (Common sense approach to vulvovaginitis symptoms.)

Pirotta, MV, Gunn, JM, Chondros, P. “"Not thrush again!" Women's experience of post-antibiotic vulvovaginitis”. Med J Aust. vol. 179. 2003. pp. 43-6.

Sobel, JD, Chaim, W, Nagappan, V, Leaman, D. “Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine”. Am J Obstet Gynecol. vol. 189. 2003. pp. 1297-300. (Study showing benefit of using boric acid and flucytosine have a role in treating this uncommon and very recalcitrant infection.)

Sobel, JD, Wiesenfeld, HC, Martens, M, Danna, P, Hooton, TM, Rompalo, A, Sperling, M, Livengood, C, Horowitz, B, Von Thron, J, Edwards, L, Panzer, H, Chu, TC. “Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis”. N Engl J Med. vol. 26. 2004. pp. 876-83. (Report of the study that defined the best treatment regimen for recurrent Candida infections.)

Young, GL, Jewell, D. “Topical treatment for vaginal candidiasis (thrush) in pregnancy”. Cochrane Database Syst Rev. vol. 4. 2006. pp. CD000225(Review of evidence for safely treating vulvovaginal candidaisis safely in pregnant women.)