The treatment of Vulvovaginal Candidiasis is determined by the severity of symptoms and the frequency of episodes. Vulvovaginal Candidiasis can be categorized as uncomplicated or complicated; recurrent Vulvovaginal Candidiasis is a type of complicated infection. Complicated infections occur in only about 5% of women. These more severe infections may occur because of host factors — an inability of normal factors to prevent candidal colonization — or the presence of fungal organisms that are more resistant to azole antifungal therapy.
The goals of therapy for vaginal fungal infections are (1) relief of symptoms, (2) eradication of the infection, and (3) reestablishment of normal vaginal flora.
A single course of drag therapy is effective in achieving these goals for virtually all patients. However, a small percentage of patients will experience persistent or recurrent infections and will require prolonged therapy or higher doses of medication.
General Treatment Approach
Self-treatment of Vulvovaginal Candidiasis with nonprescription antifungal therapy can be appropriate for patients with uncomplicated disease (infrequent episodes, mild-to-moderate symptoms), whereas women with complicated (more severe symptoms, or concurrent predisposing illness or medications) or recurrent infections should be referred for assessment and treatment by a primary care provider. (See Figure 8-1 for a list of exclusions for self-care.)
By definition, recurrent Vulvovaginal Candidiasis occurs when a woman experiences at least four (documented) infections within a 12-month period. Patients with such symptoms should be evaluated for the possibility of a mixed infection or a strain of Candida] infection other than C. albicans, which may be resistant to standard therapy. Recurrent candidal infections often require long-term suppressive prophylactic therapy. About two-thirds of surveyed physicians report seeing patients who had delayed treatment because of inappropriate use of nonprescription products.’ In addition, frequent or recurrent episodes of Vulvovaginal Candidiasis may be an early-sign of HIV infection or diabetes. The Food and Drug Administration (FDA) now requires labels of nonprescription products to include a warning similar to the following:
Symptoms that return within 2 months or infections that do not clear up easily with proper treatment require medical evaluation. Possible causes of the infection include pregnancy or a serious underlying medical disorder, such as diabetes or a damaged immune system (including damage from infection with HIV. the virus that causes acquired immunodeficiency syndrome).
Preventive measures are not a standard part of therapy for vaginal fungal infections. However, women with infections that are more frequent or are not responsive to antifungal therapy may try dietary changes; nondrug measures (e.g.. avoidance of nonabsorbent clothing): or alteration in other drug therapy known to be a risk factor for Vulvovaginal Candidiasis. A 3- to 4-month trial of these approaches will reveal whether they are useful for individual patients. Figure 8-1 outlines the appropriate approach to treating the patient with vaginal symptoms.
Decreased consumption of sucrose and refined carbohydrates, as well as consumption of yogurt containing live cultures (see Complementary Therapies), have been suggested as measures to decrease Vulvovaginal Candidiasis, particularly for women who experience recurrent infections.
Discontinuing a drug known to increase susceptibility to vaginal fungal infections might be effective in decreasing the incidence of this disorder. Low-dose oral contraceptives are unlikely to contribute to the occurrence of Vulvovaginal Candidiasis, but they might be discontinued to see whether the frequency of infection is altered. Patients taking broad-spectrum antibiotics or immunosuppressants should consult their primary care provider before discontinuing these medications.
Currently, a nonprescription. FDA-approved imidazole (butoconazole, clotrimazole, miconazole, or tioconazole) product is the recommended initial therapy for uncomplicated Vulvovaginal Candidiasis, and relief of external vulvar itching and irritation associated with the infection. These products are available as vaginal creams, suppositories, and tablets.
The major antifungal effect of the imidazole compounds is accomplished by altering the membrane permeability of the fungi. These agents inhibit cytochrome P450 enzymes in the fungal cell membrane, thereby decreasing synthesis of the essential fungal sterol ergosterol. The reduced membrane ergosterol content is accompanied by a corresponding increase in lanosterol-like methylated stcrols. These lanosterol-like sterols cause structural damage to fungal membranes, resulting in the loss of normal membrane function.
Topical vaginal imidazole preparations are not appreciably absorbed. Systemic absorption of butoconazole, clotrimazole, miconazole, and tioconazole is about 1.7%, between 3% and 10%, 1.4% and negligible amounts of a vaginal dose, respectively.* Fungicidal clotrimazole concentrations are detectable in the vaginal Quid for up to 3 days after a single 500 mg dose.
Side effects from topical imidazoles are minimal and include vulvovaginal burning, itching, and irritation in 3% to 7% of patients.- These side effects are more likely to occur with the initial application of the vaginal preparation and are similar to symptoms of the vaginal infection. Abdominal cramps (3%). penile irritation, and allergic reactions (3%-7%) are uncommon, and headache may occur in up to 9% of women.
Because of the limited absorption of topical antifungals, drug interactions are unlikely. However, a case report documented an interaction between miconazole vaginal suppositories (100-200 mg) and warfarin. In this patient, international normalized ratio (international normalized ratio) levels were significantly increased on two occasions when vaginal miconazole was used. Miconazole and warfarin are both metabolized by cytochrome P4502C9; concurrent use may decrease the clearance of warfarin and increase unbound drug. The prescriber should be contacted to consider reducing the dose of warfarin during concurrent therapy to avoid an increase in international normalized ratio. Nonprescription vaginal antifungal product information warns women using warfarin in combination with these products that bleeding or braising might occur. Aside from an allergy to the imidazoles. there are no contraindications to use of the vaginal imidazoles.
Studies have shown the imidazoles to be equally effective, with effectiveness rates of approximately 80% to 90%. Different treatment durations have been studied. Miconazole single-dose and 7-day treatments were compared, resulting in similar overall cure rates with significantly faster rates of symptom relief by day 3 in the 3-day group compared with the 7-day treatment groups. Butoconazole nitrate 2% single-dose cream has also been compared with miconazole 7-day treatment, resulting in nonsignificant differences in cure rates. Seven-day regimens of clotrimazole and miconazole, 3-day regimens of butoconazole, clotrimazole, and miconazole, and 1-day regimens of clotrimazole. miconazole. and tioconazole are available without a prescription. Monistat I has also been approved for insertion in the morning or at bedtime. A similar cure rate exists for the daytime and bedtime treatments. Table Selected Vaginal Antifungal Products and Their Dosages lists the recommended nonprescription dosage regimens for products containing these ingredients. Information on currently available prescription and nonprescription products and regimens for acute infections, recurrent infections, and prophylactic therapy is presented in several reviews.
Table Selected Vaginal Antifungal Products and Their Dosages
|Primary Ingredient||Trade Name||Dosage|
|Butoconazole Nitrate Products|
|Butoconazole nitrate 2%||Mycelex-3 Cream||Insert cream into vagina daily for 3 days; apply to vulva twice daily as needed for itching.|
|Clotrimazole 1%||Gyne-Lotrimin 7 Cream||Insert cream into vagina daily for 7 days; apply to vulva twice daily as needed for itching.|
|Tablet: clotrimazole 100 mg||Mycelex-7 Combination Pack||Insert tablet into vagina daily for 7 days; apply cream to vulva twice daily for itching.|
|Cream: clotrimazole 1%||Gyne-Lotrimin 3 Cream||Insert cream into vagina daily for 3 days; apply to vulva twice daily for itching.|
|Miconazole Nitrate Products|
|Cream: miconazole nitrate 2%||Monistat 1 Combination Pack||Apply cream to vulva twice daily as needed for itching; insert suppository into vagina daily (morning or at bedtime) for 1 day.|
|Suppository: miconazole nitrate 1200mg||Monistat 1 Daytime Ovule|
|Cream: miconazole nitrate 2%||Monistat 3 Combination Pack||Apply cream to vulva twice daily as needed for itching; insert suppository into vagina daily for 3 days.|
|Suppository: miconazole nitrate 200 mg||M-zole 3 Combination Pack|
|Miconazole nitrate 4%||Monistat 3 Cream||Insert cream into vagina daily for 3 days; apply to vulva twice daily as needed for itching.|
|Miconazole nitrate 100 mg||Monistat 7 Suppository||Insert suppository into vagina daily for 7 days.|
|Miconazole nitrate 2%||Monistat 7 Cream||Insert cream into vagina daily for 7 days; apply to vulva twice daily as needed for itching.|
|Cream: miconazole nitrate 2%||Monistat 7 Combination Pack||Apply cream to vulva twice daily as needed for itching; insert suppository into vagina daily for 7 days.|
|Suppository: miconazole nitrate 100 mg||M-zole 7 Combination Pack|
|Tioconazole 6.5%||Vagistat-1 Ointment 1-Day Ointment||Insert ointment into vagina daily for 1 day.|
Several nonspecific, nonprescription vaginal preparations, including Vagisil and Yeast-Gard (bcnzocaine and resorcinol) and Vaginex (tripelennamine), are also available. These agents are used for the relief of itching; however, they do not address the cause of the itching in the case of Vulvovaginal Candidiasis. The use of these agents for Vulvovaginal Candidiasis is rarely, if ever, appropriate given the obvious advantages of the azole antifung.ils. including superior efficacy, improved patient compliance associated with ease of use. less frequent local reactions, and shorter treatment durations. The nonspecific products and medicated douches are more appropriate for vaginal and vulvar irritation and itching. They should be used for a limited time or on the advice of a primacy care provider. ()
Table Selected Products for Vaginal Itching and Irritation
|Primary Ingredients||Trade Names|
|Benzocaine 6%; benzethonium chloride 0.1%||Lanacane Creme|
|Benzocaine 5%; resorcinol 2%||Vagi-Gard Advanced Sensitive Cream
Vagisil Anti-itch Original Formula
|Benzocaine 20%; resorcinol 3%||Vagisil Maximum Strength
Vagi-Gard Maximum Strength Cream
|Benzocaine 5%; benzalkonium chloride 0.13%||Vagi-Gard Cream|
|Hydrocortisone 0.5%||Cortef Feminine Itch Cream
Massengill Medicated Towelette
|Hydrocortisone 1%||Gyne-cort Female Cream|
|Povidone/iodine 10%||Betadine Medicated Suppository|
|Povidone/iodine 0.3% (in disposable bottles)||Betadine Premixed Medicated Disposable Douche|
|Massengill Medicated Disposable Douche|
|Summer’s Eve Special Care Medicated Douche|
|Pulsatilla (28X); Candida albicans (28X)
Candida parapsilosis (28X)
|Pulsatilla (28X)||Yeast-X Suppository|
|Cornstarch; aloe; mineral oil||Summer’s Eve Feminine Powder’|
|Vagisil Feminine Powder*|
Product Selection Guidelines
Self-treatment of Vulvovaginal Candidiasis is not appropriate for girls younger than 12 years. This condition is rare in premenarchal girls, and any vaginal symptoms in this age group warrant a medical referral to determine the cause. Vaginal infections in prepubertal children may indicate potential sexual abuse.
Treannent of Vulvovaginal Candidiasis in pregnancy should consist of one of the imidazoles (butoconazole, clotrimazole, or miconazole); however, when possible, withholding treatment during the first trimester may be preferable. Self-treatment during pregnancy is not appropriate. Prescriber assessment is important to evaluate for complications (e.g., elevated blood sugar) and to assess for other vaginal organisms, because bacterial vaginosis and trichomoniasis have the potential for adverse pregnancy outcomes. Breast-feeding women can use any of the nonprescription vaginal antirungals.
No special considerations are necessary to treat geriatric patients presenting with a WC infection.
Selection of cream, tablet, or suppository formulations can be left to patient preference; some patients may prefer the convenience of prefilled applicators. Studies have found that women who have previously experienced Vulvovaginal Candidiasis prefer shorter courses of therapy than do women who have not had a prior infection; physicians tend to prefer longer courses of therapy.If vulvar symptoms are significant, a cream preparation, or the combination of a cream with vaginal suppositories or tablets is preferred.
Complementary Therapies for Vaginitis
An alternative approach to treating Vulvovaginal Candidiasis is the use of Lactobacillus preparations. The rationale for use of these preparations is to reestablish normal vaginal flora and inhibit overgrowth of Candida organisms. Data on the effectiveness of this approach are limited; one study that treated five women with positive vaginal cultures for C. albicans found 4 of the 5 women had negative cultures after administration of Ladobacillus GG suppositories for 7 days. However, another study examining the usefulness of Lactobacillus and other pro-biotic bacteria administered orally, vaginally. and by both routes found that none of the regimens protected against the development of postantibiotic Vulvovaginal Candidiasis.il However, eating yogurt with live cultures (8 ounces daily) may be of some benefit in preventing recurrent Vulvovaginal Candidiasis. ()
Home remedies such as vaginal douches of yogurt or vinegar have also been used to treat this condition but are generally not effective. However, use of a sodium bicarbonate sitz bath may provide prompt relief ol vulvar irritation associated with a Candida! vaginal infection before antifungal agents can provide benefit:
- Add 1 teaspoon sodium bicarbonate to 1 pint of water.
- Add 2 to 4 tablespoons of the solution to 2 inches of bath water.
- Sit in the sitz bath or bathtub for 15 minutes as needed for symptom control.
Some women may prefer herbal products to manage Vulvovaginal Candidiasis. An herbal product used for the treatment of Vulvovaginal Candidiasis is tea tree oil (vaginal preparations). Tea tree oil has antibacterial and antifungal properties, and Lactobacillus organisms are more resistant to tea tree oil than are organisms associated with BV. A 200 nig vaginal suppository containing tea tree oil is also available commercially. It is used nightly for 6 nights. The possibility of allergic dermatitis exists. ()
Gentian violet (a dye available in community pharmacies) is an old treatment for Vulvovaginal Candidiasis, which is generally used today as therapy for resistant Candidal infections. It is available on the nonprescription market and can be used as topical therapy; a tampon can be soaked in the dye and inserted into the vagina. The tampon is left in the vagina for several hours or overnight. Often a single application is adequate, but tampons saturated with gentian violet can be used once or twice a day for up to 5 consecutive days. The major disadvantage of using gentian violet is that it can stain fabrics and skin.
Another option for the treatment of Vulvovaginal Candidiasis is boric acid. The regimen is boric acid 600 mg in a size 0 gelatin capsule inserted vaginally once or twice daily for 14 days. Boric acid 5% in lanolin can be applied topically for vulvar irritation. Boric acid therapy is particularly useful for non-C. albicans infections, which are more likely to be resistant to the azole antifungals. High short-term cure rates have been reported (85%-95%) when boric acid is used following treatment failure with another antifungal. For resistant cases, the therapy-is used twice weekly for longer durations. Boric acid can be toxic and teratogenic; human fatalities have been reported from oral ingestion. Boric acid capsules may be compounded in community pharmacies, and counseling should be provided to explain that the capsule should not be ingested and that pregnant women should not use boric acid.