Valvovaginal candiasiai
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Vulvovaginal candidiasis (VVC) is a fungal infection of the vagina and vulva, most commonly caused by Candida albicans. It presents with thick, white ("cottage cheese") discharge, vulvovaginal itching, burning, and erythema. Treatment is with azole antifungals (topical or oral fluconazole).
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"vulvovaginal candidiasis"[MeSH Terms] AND treatment
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Here is a thorough clinical overview of Vulvovaginal Candidiasis (VVC):
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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