Vulvovaginal Candidiasis (VVC)

Epidemiology

~75% of women experience at least one episode in their lifetime
~45% will have two or more episodes
Candida albicans causes 85-90% of cases
Non-albicans species (C. glabrata, C. tropicalis) account for the remainder and tend to be more resistant to therapy

Pathogenesis

Candida are dimorphic fungi existing in two forms:

Blastospores - responsible for transmission and asymptomatic colonization
Mycelia (hyphae) - arise from blastospore germination, enhance colonization, and facilitate tissue invasion

Symptomatic disease is associated with organism concentrations >10^4 per mL (vs. <10^3/mL in asymptomatic colonization). A hypersensitivity mechanism may drive symptoms, particularly in recurrent cases.

Predisposing Factors

Antibiotic use (disrupts normal vaginal flora)
Pregnancy
Diabetes mellitus
Immunosuppression (HIV, corticosteroids, chemotherapy)

Both pregnancy and diabetes are linked to a qualitative decrease in cell-mediated immunity.

Classification: Uncomplicated vs. Complicated

Feature	Uncomplicated	Complicated
Frequency	Sporadic / infrequent	Recurrent (≥4/year)
Severity	Mild to moderate	Severe
Organism	Likely C. albicans	Non-albicans Candida
Host	Immunocompetent	Immunocompromised, diabetic, HIV

Clinical Features

Vulvar pruritus - hallmark symptom (absence argues against VVC)
Vaginal discharge - classically thick, white, "cottage cheese" or curd-like, odorless
Vaginal soreness, dyspareunia
Vulvar burning and irritation
External dysuria ("splash" dysuria - urine contacts inflamed vulvar epithelium)

Exam findings:

Erythema and edema of the labia and vulvar skin
Discrete pustulopapular peripheral lesions
Erythematous vagina with adherent whitish discharge
Cervix appears normal

Key diagnostic clue: Inflammation of vulva + lack of odor + thick curdy discharge = high likelihood of candidiasis.

Diagnosis

Vaginal pH - typically normal (<4.5); elevated pH suggests bacterial vaginosis or trichomoniasis
KOH preparation - reveals budding yeast forms or branching mycelia/pseudohyphae in ~80% of cases
Whiff (amine) test - negative (positive in BV)
Saline prep - usually normal; may show slight increase in inflammatory cells in severe cases
A presumptive diagnosis can be made without microscopy if pH is normal, saline prep is normal, and erythema is present on exam
Culture - reserved for recurrent or treatment-resistant cases to identify non-albicans species

Treatment

Uncomplicated VVC

Topical azoles (first-line, more effective than nystatin; 80-90% cure rate):

Agent	Regimen
Butoconazole 2% cream	5 g intravaginally, single dose
Clotrimazole 1% cream	5 g intravaginally x 7-14 days
Clotrimazole 2% cream	5 g intravaginally x 3 days
Miconazole 2% cream	5 g intravaginally x 7 days
Miconazole 200 mg suppository	1 suppository x 3 days
Terconazole 0.4% cream	5 g intravaginally x 7 days
Tioconazole 6.5% ointment	5 g intravaginally, single dose
Nystatin 100,000 U tablet	1 tablet x 14 days

Oral azole:

Fluconazole 150 mg orally, single dose - equal efficacy to topical azoles for mild-moderate VVC; symptoms persist 2-3 days after treatment (warn patients)

Note: Oil-based topical formulations may weaken latex condoms.

Complicated VVC

Fluconazole 150 mg x 2 doses - second dose 72 hours after first
Or prolonged topical azole therapy (10-14 days)
Adjunctive 1% hydrocortisone cream to the vulva for external irritation relief

Recurrent VVC (RVVC)

Defined as 4 or more episodes per year. Non-albicans species found in 10-20% of RVVC. Burning (rather than itching) becomes the predominant symptom.

Important: Many women with presumed RVVC actually have chronic atopic dermatitis or atrophic vulvovaginitis - always confirm diagnosis with microscopy and fungal culture.

Management:

Induction: Fluconazole 150 mg every 3 days x 3 doses
Maintenance (suppression): Fluconazole 150 mg weekly x 6 months
- 90% remain in remission on this regimen
- After stopping, ~50% relapse - reinstitute suppressive therapy if recurrence occurs
If non-albicans species identified or fluconazole resistance suspected:
- Boric acid 600 mg vaginal suppository x 14 days

Differential Diagnosis

Bacterial vaginosis (fishy odor, elevated pH, clue cells, positive whiff test)
Trichomonas vaginitis (frothy yellow-green discharge, motile trichomonads on wet prep, strawberry cervix)
Atrophic vaginitis (postmenopausal, parabasal cells on wet prep, responds to estrogen)
Desquamative inflammatory vaginitis (purulent discharge, pH >4.5, gram-positive cocci on Gram stain)
Contact/irritant dermatitis

Sources: Berek & Novak's Gynecology, pp. 811-813; Symptom to Diagnosis: An Evidence Based Guide, 4th Ed.

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