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VULVOVAGINAL CANDIDIASIS

  • Vulvovaginal candidiasis (VVC) refers to infections in individuals with or without symptoms who have positive vaginal cultures for Candida species. It may be sporadic or recurrent.

  • By 25 years of age, approximately 50% of college-age women will have had at least one episode of VVC.

Pathophysiology

  • C. albicans is the major pathogen responsible for VVC, accounting for 80%–92% of symptomatic episodes. The remainder are caused by non–C. albicans species, with Candida glabrata dominating.

  • Changes in the host’s vaginal environment or response are necessary to induce a symptomatic infection. In most cases of symptomatic VVC, no precipitating factor can be identified.

Clinical Presentation

  • There is a dramatic increase in the frequency of VVC when women become sexually active.

  • Antibiotic use can increase the risk of VVC, but it is significant in only a small number of women.

  • Symptoms include intense vulvar itching, soreness irritation, burning on urination, and dyspareunia.

  • Signs include erythema, fissuring, curdy “cheese”-like discharge, satellite lesions, and edema.

  • Laboratory tests: Vaginal pH—normal saline, and 10% potassium hydroxide (KOH) microscopy for blastospores or pseudohyphae.

  • Candida cultures are not recommended unless classic signs and symptoms with normal vaginal pH and microscopy are inconclusive or recurrence is suspected.

  • The diagnosis should be based on both clinical presentation and investigations, including vaginal pH, saline microscopy, and 10% KOH microscopy of vaginal discharge.

Treatment

  • Goals of Treatment: Complete resolution of symptoms in patients who have symptomatic VVC.

General Approach

  • Remove or improve any predisposing factors if they can be identified.

  • Avoid harsh soaps and perfumes that can cause or worsen vulvar irritation. The genital area must be kept clean and dry by avoiding constrictive clothing and frequent or prolonged exposure to hot tub use. Douching is not recommended for either prevention or treatment.

Nonpharmacologic Therapy

  • The value of oral use of lactobacillus remains unclear. Daily ingestion of 240 mL yogurt containing Lactobacillus acidophilus decreased colonization and symptomatic infections of VVC in women with recurrent infections.

  • A trial of an oral mixture of bee-honey and yogurt showed some efficacy with mycotic cure rates of 76.9% compared to cure rates with antifungal agents of 91.5%.

Pharmacologic Therapy

  • Effective antimycotic agents should have limited local and systemic side effects, a high cure rate, and easy administration.

  • Table 39-1 lists treatments for uncomplicated VVC. There are no significant differences in in-vitro activity or clinical efficacy among the topical azole agents. Oral azoles (such as fluconazole or itraconazole) are therapeutically equivalent to topical therapies.

  • Patients with complicated VVC (immunocompromised or uncontrolled diabetes mellitus) should be treated for 10–14 days.

  • Pregnant patients with VVC should be treated with topical agents.

  • Patients with recurrent VVC should receive a 10-day initial ...

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