Candida vulvovaginitis

Background

• Local fungal infection caused by the Candida genus
• Most commonly seen in females in high estrogen states: pregnancy, oral contraceptive use, obesity, diabetes mellitus
• Not considered an STI although it can be transmitted by sexual intercourse
• May occur in premarnarcheal girls (rare)

Types

• Uncomplicated
  • Sporadic infectionn
  • mild-moderate symptoms
  • due to Candida albicans
  • immunocompetent
• Complicated
  • Recurrent infection
  • severe symptoms
  • uncontrolled DM
  • immunosuppression
  • pregnant

Clinical Features

Candida vaginitis

• Vulvar pruritus - most common and specific symptom
• Vaginal discharge - varies from little to copious and from watery to cottage-cheese like
• Malodorous smell is unusual (if present favors diagnosis of Bacterial vaginosis)
• intense vulvovaginal pruritus or burning
• dyspareunia
• dysuria

Differential Diagnosis

Vulvovaginitis

• Bacterial vaginosis
• Candida vaginitis
• Trichomonas vaginalis
• Contact vulvovaginitis
  • Bubble baths and soaps
  • Deodorants, powders, and douches
  • Clothing
• Atrophic vaginitis due to lack of estrogen (AKA Vulvovaginal atrophy)
• Lichen sclerosus
• Tinea cruris
• Chlamydia/Gonorrhea infection
• Pinworms
• Vaginal foreign body
  • Toilet paper
  • Other
• Genitourinary syndrome of menopause
• Foreign body
• Allergic reaction
• Normal physiologic discharge

Evaluation

Work-up

• Wet mount - shows hyphae and yeast buds
  • Candida does not cause WBCs on wet mount → if present, consider co-infection with other vaginitides or STI
• If recurrent, consider checking blood glucose for occult DM

Diagnosis

• although other candida infections are clinically diagnosed, laboratory methods should be pursued to confirm diagnosis of candida vulvovaginitis
• cotton cheese curd-like non-odorous vaginal discharge on pelvic exam
• vaginal pH < 4.5
• vaginal wet mount

Management

• Do not treat if asymptomatic
• Sexual partners should not be treated unless the patient has frequent recurrences
• Antifungal
  • 1st line: Oral Fluconazole
  • Pregnant: Topical imidazole (clotrimazole, miconazole)

Antifungals

Uncomplicated

There is little resistance to azole medications; treatment often dictated by patient preference.

• Fluconazole 150mg PO once (preferred)
  • A second dose at 72hrs may be given if patient is still symptomatic
• Intravaginal therapy
  • Clotrimazole 1 % cream applied vaginally for 7 days OR
  • Clotrimazole 2% applied vaginally for 3 days
  • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
  • Butoconazole 2% applied vaginally x 3 days
  • Tioconazole 6.5% applied vaginally x 1

Complicated

Severe or immunosuppressed

• Fluconazole 150mg PO q72h x 3 doses

Non-albicans species

• For example, C. glabrata, C. krusei and other atypical Candida spp.
• Boric acid vaginal suppository intravaginal qday x ≥14 days
  • Can be fatal if taken orally
• If empirically treated and later is found to have non-albicans Candida spp., no change in therapy is needed if patient is improving (otherwise switch to boric acid.

Recurrent (≥ 4 infections in a year)

• Treat as for uncomplicated (see above)
• Once therapy completed, prescribe long-term treatment
  • Fluconazole 150mg PO qweek x 6 months, OR
  • Intravaginal medication, such as clotrimazole 500mg PV qweek or 200mg PV twice a week

Pregnant Patients

• Intravaginal clotrimazole or miconazole are the only recommended treatments
• Duration is 7 days
• PO fluconazole associated with congenital malformations and spontaneous abortions

Disposition

• Outpatient

See Also

• Vulvovaginitis
• Candidiasis