Vulvovaginal candidiasis (VVC), commonly referred to as yeast infection, is the second most common cause of vaginitis in the United States. Approximately 75% of all women will experience an episode of VVC in their lifetime, with recurrent vulvovaginal candidiasis occurring in 5% of women. It is most commonly caused by the fungus Candida albicans; however, other Candida species, such as C. tropicalis and C. glabrata are becoming increasingly common, possibly because of increased use of OTC anti-fungals, and they are also typically more resistant to antifungal treatments. OTC antifungal treatments are among the top 10 selling OTC medications in the United States with an estimated $250 in annual sales. Establishing Candida as a cause of vaginitis can be difficult, because 50% of all women have Candida organisms as part of their normal vaginal flora. Candida is not considered a sexually transmitted disease, and conventional medical practice does not include treatment of male partners unless uncircumcised or presenting with inflammation of the glans penis. recurrent vulvovaginal candidiasis is defined as four or more episodes annually. Recurrence may be a result of associated factors, intestinal microorganism reservoir, vaginal persistence, or sexual transmission. Genital candidiasis is associated with antibiotic use, oral contraceptives and HRT, and other drugs that change the vaginal environment to favor proliferation of Candida. Vaginal yeast infections are also more common during pregnancy and menstruation, and in diabetics. Drugs and diseases that suppress the immune system can facilitate infection.
Causes and Risk Factors for Developing Vulvovaginal Candidiasis
Reported risk factors include:
- • Recent / repeated antibiotic use
- • Diabetes mellitus
- • HIV infections / AIDS
- • Increased estrogen levels (e.g., hormonal dysregulation, HRT)
- • Pregnancy
- • Hyperglycemia
Additional factors may include anything that disrupts the normal balance of vaginal flora, which are listed in Table Common Causative Organisms, Agents, and Conditions Involved in the Etiology of Vulvovaginitis.
Women with vulvovaginal candidiasis often develop mild to severe itching and irritation of the vulva and may have a vaginal discharge characteristically curd-like in appearance with a mild yeast-like odor. The vulva may be red, inflamed, and swollen and the tissue may become raw and fissured, particularly from scratching to relieve itch, which should be discouraged. Note that these symptoms are not specific only to VVC, and therefore other causes should also be ruled out. Physical findings in women with vulvovaginal candidiasis include vulvar and / or vaginal erythema, edematous labia minora, appearance of vaginal thrush, and normal pH.
One or more of these symptoms are typically reported by patients with VVC:
- • Vulvovaginal pruritus
- • Vulvovaginal irritation
- • Vulvovaginal swelling
- • Dysuria
- • Thick, whitish vaginal discharge
- • Possible odor to vaginal discharge (characteristic “yeasted bread-like” odor)
Definitive diagnosis of Candida can be based on positive microscopic findings. Cultures are expensive, but obtaining a positive fungal culture can be important for the diagnosis and effective treatment of recurrent vulvovaginal candidiasis. Candida vaginitis is associated with a normal vaginal pH (<4.5). Identifying Candida by culture in the absence of symptoms is not an indication for treatment, because it is a part of the normal endogenous flora.
Conventional Treatment Approaches of Vulvovaginal Candidiasis
Uncomplicated vulvovaginal candidiasis is intermittent and infrequent, and in 80% to 90% of cases results in resolution of symptoms and negative culture after a short course of topical azole drugs. Examples of azole-containing antifungal creams include: clotrimazole, miconazole, ketoconazole, and fluconazole. These are currently available OTC. The duration of treatment with these preparations may be 1, 3, or 7 days. Alternatively, ketoconazole, fluconazole (Diflucan), itraconazole, or Nystatin can be taken orally. Self-medication with OTC preparations should be advised only for women who have been diagnosed previously with vaginal Candida infection and who have a recurrence of the same symptoms. Any woman whose symptoms persist after using an OTC preparation or who has a recurrence of symptoms within 2 months should seek medical care. Treatment with azoles results in relief of symptoms and negative cultures among 80% to 90% of patients who complete therapy. Topical agents usually are free of systemic side effects, although local burning or irritation may occur. A maximum of 7 days of topical therapy is recommended during pregnancy. Oral agents lead to better compliance but have a greater risk for systemic toxicity, and occasionally may cause nausea, abdominal pain, dizziness, rash, or headaches. Therapy with the oral azoles occasionally has been associated with abnormal elevations of liver enzymes. Occasionally, women who take oral contraceptives must stop using them for several months during treatment for vaginal candidiasis because they can worsen the infection. Women who are at unavoidable risk of vaginal candidiasis, such as those who have an impaired immune system or who are taking antibiotics for a long period of time, may need an antifungal drug or other preventive therapy. For women with complicated vulvovaginal candidiasis (RVVC), a longer duration of therapy may be recommended, followed by a 6-month period of maintenance therapy. Azole drugs may significantly interact with a number of drugs (e.g., astemizole, cisa-pride, Hl-antihistamines interactions have been associated with cardiac dysrhythmia) owing to potent inhibition of cytochrome P3A4, leading to increased bioavailability of the interacting drug.