External: Clotrimazole cream (1% and 2%, topically, three times daily), or Econazole cream (1%, twice daily) or Ketoconazole cream (2% twice daily) or Miconazole cream (2% twice daily),or Nystatin cream (100,000U/g, four times daily), all for 7-10 days.
Clotrimazole, Econazole and Nystatin are also available in preparations containing Hydrocortisone.
Intra-vaginal preparations could be used in addition to the external creams as there is concurrent Candidal Vaginitis, with the Vulvitis. Clotrimazole, vaginal pessaries (500mg single dose, 200mg for three nights or 100mg for six nights) or, Clotrimazole cream (10% in a single 5gm application) or, Econazole pessary (150mg in a single dose, or repeated for three nights) or, Miconazole Ovule (1.2 gm in a single dose) or Miconazole pessary (200mg for seven nights) or Miconazole cream (2%, 5gm applications, daily for two weeks).
Oral therapy is preferred by patients who consider the topical applications messy. Oral therapy should be avoided during pregnancy or lactation. Oral preparations include: Fluconazole (50mg, in a single dose) or Itraconazole (200mg, twice daily for 1 day).
Recurrent vulvo-vaginal candidiasis patients may follow one of two approaches in the management. Maintenance therapy has the advantage of a respite but caries the disadvantage of recurrence in up to half of the patients after cessation of treatment. Fluconazole (100 mg orally, weekly) or Clotrinazole (500mg vaginal pessary, weekly) or Itraconazole (400mg, orally, once/month) could be used. Episodic treatment has the benefit of confirmed diagnosis and avoidance of over-treatment.
Male Patients: Partners of patients suffering with RVVC do not require treatment. There is no evidence that treatment of the male partner reduces recurrences. Patients suffering with Candidal Balanoposthitis benefit from saline lavage for the preputial sac; insuring rinse and dry conditions following the lavage. Moderate and severe Balanoposthitis require topical treatment; for example, Clotrimazole cream (2% twice daily), or Ketconazole cream (2%, twice daily). The Hydrocortisone containing antifungal preparations are valuable, when there is an element of hypersensitivity. They should not be used for extended periods or without medical supervision. The can conceal the diagnosis of an underlying and un- diagnosed dermatological condition (e.g., Balanitis Xerotica Obliterans). There are advantages for the patient to develop a habit of regular saline lavage of the preputial sac, on daily basis, which may eliminate or reduce recurrencies.
Vulvo-Vaginal Candidiasis: Clinical Practicalities
- Culture alone is not enough for the diagnosis of VVC, as the yeasts are commencals and colonisation affects up to 20% of the population.
- Germ tube formation could identify C.albicans; C glabrata do not develop hyphae.
- Culture can identify the species and consequently guide therapy.
- Direct Microscopy of saline wet-mounted preparation can identify pseudo-hyphae and/or spores; which could also be identified on Gram-stained smears. C.glabrata produce spores only but no hyphae.
- Skin scrapings could be used for the preparation of Gram-stained smears, for microscopy, or cultures.
- The microscopy and culture tests are not done in isolation but as part of a comprehensive investigation of the patient’s condition. Concurrent other sexually transmitted infections should be considered and excluded.
- The patient would benefit from measures to avoid rising genital skin humidity and temperature (e.g., tight, synthetic clothes and underwear). She should be adviced to avoid conditions that may produce additional hyper-sensitivity (e.g., perfumed products).
- Saline genital wash/bath has the benefit of discouraging fungal overgrowth, due to high osmolarity and its effect on the organism.
- The use of vulval skin moisturising agents have a beneficial soothing effect.
- The patient’s choice on the route of drug administration should be considered. There are good clinical responses to either topical and/or oral preparations.
- Topical creams have a soothing effect.
- Topical anti-mycotics containing hydrocortisone could be used for short periods. These have the advantage of symptomatic relief when there are hyper sensitivity reactions. They carry the disadvantage of masking underlying pathology (e.g., mild Vulval Lichen Sclerosous), which could be the predisposing factor to RVVC.
- The suspicion of underlying vulval dermatological conditions (e.g., Lichen Sclerosous) should withhold the use of topical steroids, until a confirmed diagnosis is made. Steroids may distort the clinical and/or histological pictures of the underlying dermatological condition.
- The possible damage to latex condoms by topical preparations should be explained to the patient.
- There are Anecdotal reports of benefits from alternative-medicine; but without evidence based conclusions.
- Drug resistance is common with C glabrata (e.g.,Clotrimazole, Miconazole).
- Nystatin resistance is rare and there are benefits of its use with C glabrata infection.
Selections from the book: “Sexually Transmitted Diseases”, Edited by A. R. Markos, 2009. Series “Disorders of the Lower Genito Urinary Tract”.