Patients experiencing their initial episode of vulvovaginal candidiasis can be treated with any of the antifungal topical agents (Table Available antifungal agents). The importance of initiating treatment is to establish if the patient has a yeast infection and if the yeast is a hyphal-producing species. If the examiner finds only budding yeast in the vaginal discharge it is significantly possible that the patient will not respond to typical antifungal agents. The patient should be examined within 1 — 2 weeks of completing treatment to determine if her condition has resolved. There is no need to culture the individual experiencing her first episode if yeast are documented on microscopic examination of the vaginal discharge. If the patient has symptoms and physical findings consistent with vulvovaginal candidiasis, but microscopic examination of her vaginal discharge does not reveal yeast, then a vaginal specimen should be obtained for the culture of yeast.
Table Available antifungal agents
|Fluconazole (Diflucan) 150 mg oral tablet administered once a week|
|Clotrimazole 1 % cream (Femzol-7) 7-day therapy|
|Clotrimazole 1% cream (Gyne-Lotrimin) 7-day therapy|
|Clotrimazole 100 mg vaginal tablets (Gyne-Lotrimin) 7-day therapy|
|Clotrimazole 200 mg vaginal tablets (Gyne-Lotrimin) 3-day therapy|
|Butoconazole 2% cream (Femstat-3) 3-day therapy|
|Butoconazole 2% emulsion (Gynazol-1) single-dose intravaginal therapy|
|Miconazole 2% cream (Femzol-M) 7-day therapy|
|Miconazole 2% cream (Monistat-7) 7-day therapy|
|Miconazole 200 mg vaginal tablet (Monistat-3) 3-day therapy|
|Miconazole 100 mg vaginal tablet (Monistat-7) 7-day therapy|
|Terconazole 0.8% cream (Terazole-3) 3-day therapy|
|Terconazole 80 mg vaginal suppositories (Terazole-3) 3-day therapy|
|Tioconazole (Vagistat-1, Monstat-1) ointment, single-dose treatment|
Patients who experience a recurrent episode of vulvovaginal candidiasis but have less than four episodes in a year, should be treated with one of the antifungal agents listed in Table Available antifungal agents. Again a culture should be obtained to ensure that the patient is colonized with C. albicans and not a non-albicans species. The presence of a recurrence, although not chronic or persistent yeast vaginitis, can imply that the initial treatment was not satisfactory. If the patient became asymptomatic after initial treatment, the number of yeast may have been reduced to a number that was low enough not to initiate symptoms. When conditions in the vagina are appropriate for the increased growth of yeast, the increased number causes symptoms.
The patient with a true recurrent yeast infection, i.e. more than four infections in a 12-month period, presents a problem similar to the patient with persistent or chronic vulvovaginal candidiasis. It is important to review the patient’s hygiene because she may be re-inoculating herself from possible rectal colonization. Another possible source of re-infection or re-inoculation is orogenital sex. If either her or her partner’s oral cavity becomes colonized, they could transmit the yeast to one another via fellatio and cunnilingus. Thus, in the patient with recurrent vulvovaginal candidiasis it may be prudent to culture both the oral cavity and the rectum to determine if yeast is present. Sobel found that oral colonization occurred in 20 of 48 women (42%) with recurrent vulvovaginal candidiasis and rectal colonization occurred in 35 of 48 (73%) of the patients. Sobel also reported that 80% of the rectal isolates were identical to the vaginal isolates, and patients with positive oral cultures were usually found to have positive rectal cultures. In the male sexual partners of women with vulvovaginal candidiasis, Sobel also found that 26% had positive penile cultures. None of these patients had positive oral cultures. Seven male partners with negative penile cultures were found to have positive oral cultures for Candida, and these isolates were identical to those from their female partner’s vagina. Although this was a relatively small study and the investigator did not report on the sexual practices of the patients in the study, the data does indicate that the male partner can become colonized and it is possible that yeast was transmitted via sexual contact.
When attempting to treat a patient with recurrent or chronic vulvovaginal candidiasis, it is not unreasonable to inquire if the patient and her partner practice orogenital sex, and whether or not they have anal intercourse. If there is oral-genital contact and/or anal intercourse, then the treatment regimen should provide antifungal coverage for these sites as well as the vagina.
Suggested management for the patient with recurrent vulvovaginal candidiasis:
(1) obtain a detailed history, including diet, medications, and sexual practices;
(2) thoroughly examine the external genitalia, and note the presence of discharge, consistency, presence of erythema, edema, swelling, excoriations, skin changes (such as thickening, graying, or thinning), and other lesions;
(3) determine the vaginal pH. A pH 5 may indicate the presence of more than one infection or abnormal condition;
(4) obtain a specimen from the vagina for culture and identification of yeast; and
(5) examine a portion of the vaginal discharge microscopically and record the observations accurately.
Treatment regimens for recurrent vulvovaginal candidiasis:
(l) boric acid vaginal capsules, 600 mg, inserted intravaginally twice a day for 10 — 14 days;
(2) oralnystatin lozenges or pastilles, 400 000 IU q.i.d for 10 days in an attempt to reduce the oral and rectal colonization;
(3) re-examine the patient within 1 week after completion of therapy, determine the pH, and perform both a microscopic examination of the vaginal discharge and a culture. The culture is needed to determine if yeast is still present and the identity of the yeast. If the patient is asymptomatic, there are no physical findings of candidiasis or vaginitis, and the pH is < 4.S, therapy can be considered successful;
(4) begin suppressive therapy — fluconazole 150 mg once a month at the time of menses for 6 months.
Alternative suppressive therapies include fluconazole 150 mg once a week for 6 weeks, and intravaginal applications of butoconazole 2% cream (Gynazol-1 ) once a month for 6 months or weekly for 6 weeks. Patients with recurrent vulvovaginal candidiasis who participate in orogenital sex or anal intercourse should be treated as above but they should also be administered nystatin lozenges or pastilles. Evans and co-workers successfully treated 28 oral candidiasis patients with 200 000 IU of nystatin four times a day for 7 days. Of the 45 patients initially enrolled in their study, 36 were culture positive for Candida and completed follow-up. A total of 28 (78%) patients had a satisfactory response, and 22 (61%) had complete resolution of symptoms and signs of infection, but only ten (28%) were culture negative. A total of 23 (88%) had clinical improvement and three (11.5%) failed therapy. There has been much discussion in the literature regarding the emergence of resistant Candida strains. Resistance of C. albicans has not emerged as a significant problem. In a recent study by Bauters and co-workers, 612 women were studied and 39 (6.3%) had clinical vulvovaginal candidiasis. These investigators found an overgrowth of Candida colonization in 20% of the women, with C. albicans the most frequently isolated species (68.3%), C. glabrata second (16.3%), and C. parapsilosis third in 6.9% of the women. Other species isolated were C. humicola (in two women), C. husei (one), C. lusitaniae (one), Rhodotorula spp. (three), and S. cerevisiae (one). Among the 84 isolates of C. albicans, 24 were resistant to fluconazole. Among the 20 isolates of C. glabrata, three were considered resistant to fluconazole. Nyirjesy and colleagues report treatment outcomes for 74 patients diagnosed with chronic vulvovaginal candidiasis. They found that 68% of the isolates were C. albicans and 32% were non-albicans species. They reported that all 51 of 51 patients were successfully treated with fluconazole but seven patients experienced recurrent disease. Among the non-albicans group, two of eight responded to fluconazole, three of six responded to itraconazole, four of seven responded to clotrimazole, and 11 of IS responded to intravaginal boric acid. Spinillo and co-workers evaluated 472 isolates of Candida from women with vulvovaginal candidiasis. They isolated C. albicans in 379 women (86.5%), C. glabrata in 40 (9.1%), C. parapsilosis in seven (1.6%), C. pseudotropicalis in four (0.9%), C. tropicalis in two (0.5%), C. husei in two (0.5%), C. kefir in two (0. 5%), and S. cerevisiae in two (0.5%). Again, C. albicans was the most commonly isolated followed by C. glabrata and the ratio of almost 10: 1 appears to hold steady in most studies. These investigators reported testing 100 isolates of C. albicans to a variety of azoles (miconazole, econazole, clotrimazole, ketoconazole, isoconazole) as well as nystatin and 5-fluorocytosine. They found that approximately 20 — 40% had an intermediate sensitivity to the azoles, 2% were resistant to nystatin, and 11% had an intermediate sensitivity to 5-fluorocytosine. Among the non-albicans species (17 — 44 isolates were tested) intermediate sensitivity to these same agents ranged from one to 26 isolates.
Therefore, when evaluating patients with chronic vulvovaginal candidiasis, culture is important not only to demonstrate the presence of Candida but also to determine the species. Performing sensitivities, at this point in time, appears to be warranted because when the fungus does not respond to one azole there is a high probability that it will not respond to an alternative azole.
Boric acid vaginal capsules appear to be a good primary choice for treatment of vulvovaginal candidiasis in patients who do not respond to azole therapy as well as those with a diagnosis of recurrent disease. It does not appear that the use of boric acid vaginal capsules provides satisfactory results when therapy is stopped. Guaschino and colleagues demonstrated that boric acid vaginal therapy was effective both while therapy was ongoing and when maintained for suppressive therapy, but when the therapy was withdrawn relapses occurred.
Patients who fail to respond to boric acid therapy should be referred to an infectious disease specialist. If this is not rewarding, then I suggest contacting an obstetrician/gynecologists who specializes in infectious disease.