Candida vulvovaginitis medical therapy

Candida vulvovaginitis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]

Overview

Antifungal agents are indicated in candidiasis. Commonly used drugs include Amphotericin, Clotrimazole, Nystatin, Fluconazole and Ketoconazole. It is important to consider that Candida species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with antibiotics against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

Medical Therapy

1. Uncomplicated Vulvovaginal Candidiasis

• 1.1 Recommended Regimens
  • 1.1.1 Over-the-Counter Intravaginal Agents
    • Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole 2% cream 5 g intravaginally daily for 7 days OR Miconazole 4% cream 5 g intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application
  • 1.1.2 Prescription Intravaginal Agents
    • Butoconazole 2% cream 5 g intravaginally in a single application OR Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository one suppository daily for 3 days
  • 1.1.3 Oral Agent
    • Fluconazole 150 mg orally in a single dose.
  • Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
  • Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for VVC should be evaluated clinically and tested.
  • Note: No substantial evidence exists to support using probiotics or homeopathic medications for treating VVC.
• 1.2 Management of Sex Partners
  • Uncomplicated VVC is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.
  • A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms.

• 1.3 Special Considerations
  • 1.3.1 Drug Allergy, Intolerance, and Adverse Reactions
    • Topical agents usually cause no systemic side effects.
    • Oral azoles occasionally cause nausea, abdominal pain, and headache.
    • Clinically important interactions can occur when oral azoles are administered with other drugs.

2. Complicated Vulvovaginal Candidiasis

• 2.1 Recurrent Vulvovaginal Candidiasis
  • Defined as three or more episodes of symptomatic VVC in <1 year.
  • Preferred regimen: topical therapy for 7–14 days, OR fluconazole 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
  • Maintenance regimen: fluconazole 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently) can also be considered.
  • Note: C. albicans azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.

• 2.2 Severe Vulvovaginal Candidiasis
  • Preferred regimen: either 7–14 days of topical azole or fluconazole 150 mg PO in two doses 72 hours apart.

• 2.3 Non–albicans Vulvovaginal Candidiasis
  • The optimal treatment of non–albicans Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
  • If recurrence occurs, boric acid 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.

• 2.4 Management of Sex Partners
  • No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

3. Special Considerations

• 3.1 Pregnancy
  • Preferred regimen: topical azole for 7 days
  • Note: Epidemiologic studies indicate a single 150-mg dose of fluconazole might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.

• 3.2 HIV Infection
  • Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV.
  • Long-term prophylactic therapy with fluconazole 200 mg weekly has been effective in reducing C. albicans colonization and symptomatic VVC, however this regimen is not recommended for women with HIV infection in the absence of complicated VVC.

4 Follow-Up

Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.