#Candida vulvovaginitis, uncomplicated.
–History and Physical, above.
-Symptoms: Vulvar pruritus is the dominant symptom. Vulvar burning, soreness, and irritation are common and may result in dysuria and dyspareunia. The vulva and vagina appear erythematous, and vulvar excoriation and fissures may be present. There is often little or no discharge; when present, it is classically white, thick, adherent, and clumpy (curd-like or cottage cheese-like) with no or minimal odor.
Diagnosis: Candida is seen microscopy with KOH prep, Gram Stain, or Culture of vaginal discharge, if necessary. Culture is not necessary if microscopy shows yeast, but should be obtained in: 1) Pts with clinical features of vulvovaginal candidiasis, who have normal vaginal pH and negative microscopy. 2) Patients with complicated disease (persistent or recurrent symptoms) because many of these women have nonalbicans infection resistant to azoles.
Pathogenesis: Candida is a normal vaginal flora, but when it overgrows and penetrates the superficial epithelial cells, vulvovaginitis occurs. As such, candidal vulvovaginitis is not considered an STI.
Treatment for uncomplicated candida vulvovaginitis
Treatment is indicated to relieve symptoms. Asymptomatic patients don’t need to be treated. Sexual partners don’t need to be treated (b/c candida is part of the normal flora of women).
– The treatment regimen is based on whether the woman has an uncomplicated infection (90 percent of patients) or complicated infection (10 percent of patients).
– Uncomplicated infections — Oral and topical antimycotic drugs achieve comparable clinical cure rates, which are in excess of 80 percent in uncomplicated infection
Fluconazole 150 mg PO x 1 to treat uncomplicated infections is preferred over multidose and topical regimens.
Tx of complicated cases
Require longer courses of therapy than women with uncomplicated infection.
Fluconazole 150 mg PO in two sequential doses given three days apart is preferred over topical antimycotic agents.
TX of C. glabrata
Intravaginal boric acid 600 mg capsule once daily at night for two weeks is preferred over an azole, boric acid, or flucytosine cream.
Pregnant women
Topical imidazole (clotrimazole, miconazole) vaginally for seven days preferred over a nystatin pessary or an oral azole.
Recurrent vulvovaginitis (≥4 episodes/year)
Use suppressive maintenance therapy rather than treatment of individual episodes. Use initial induction therapy with fluconazole 150 mg every 72 hours for three doses, then maintenance fluconazole 150 mg once per week for six months. Advise these patients to try to eliminate or reduce risk factors for infection e.g. douching.
Uncomplicated vs Complicated Vulvovaginal Candidiasis
| Uncomplicated disease (pt must have ALL of these features.) | Complicated disease (pt may have ANY of these features.) | |
| Symptom severity | Mild or moderate | Severe |
| Frequency | Sporadic | Recurrent |
| Organism | Suspected Candida albicans | Suspected/documented Non C. Albicans species |
| Host | Normal: Healthy non-pregnant women | Abnormal: Pregnant or other immune or altered state (eg, uncontrolled diabetes mellitus, recurrent infections, immunosuppression) |
Sample Board Case
Pt with white cottage-cheese like discharge without foul odor. Also, reports frequent douching. KOH prep in clinic today showed pseudo-hyphae. The Patient was counseled on avoiding douching. She was prescribed fluconazole 150mg PO, single dose. She will also be getting a Hga1c to test to rule out insulin resistance as a risk factor.