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vulvovaginal candidiasis

Etiology: 1) Candida albicans (85%) 2) Candida glabrata (10-15%) 3) risk factors - SGLT2 inhibitors (flozins)* * for single episode of candidiasis, continue SGLT2 inhibitor [9] Clinical manifestations: 1) large erythematous patches over the labia majora, inguinal folds, perianal skin & inner thigh 2) pruritus, burning 3) dysuria (occasional) 4) dyspareunia (occasional) 5) thick white vaginal discharge (vaginitis) Laboratory: - microscopic examination of 10-20% KOH mount of vaginal discharge - hyphae, pseudohyphae, yeast or budding spores - sensitivity of microscopy is low* [2] - pH of discharge <= 4.5 - Candida DNA in vaginal fluid * clinical findings insufficient for diagnosis; laboratory confirmation needed [2] Management: 1) miconazole (OTC) - 200 mg suppository (Monistat 3) vaginally QHS for 3 nights or 100 mg suppository vaginally QHS for 7 nights - 2% cream, 5 grams vaginally for 7 nights 2) vaginal cream QHS for 7 nights [2] a) butoconazole 2% 5 grams for 3 nights b) clotrimazole 1%, 5 grams for 7 nights (Gyne-Lotrimin) - 100 mg tablet for 7 nights or 200 mg tablet for 3 nights c) up to 14 nights (complicated C albicans vulvovaginitis) 3) fluconazole 150 mg PO a) single dose (uncomplicated C albicans vulvovaginitis) b) 3 doses 72 hours apart (complicated C albicans vulvovaginitis) [2] 4) non C albicans vulvovaginal candidiasis a) initial treatment with 7-14 days of oral or topical with non imidazole antifungal agent such as voriconazole b) frequently recurrent 5) fluconazole 150 mg PO weekly for recurrent vulvovaginal candidiasis [4] 6) boric acid vaginal suppository for azole-resistant vulvovaginal candidiasis - daily for 2 weeks, then twice a week for 6 months [7] 7) lactobacillus not helpful [6] 8) mitigation of risk factors - for single episode of candidiasis, continue SGLT2 inhibitor [9] * empiric therapy indicated if symptoms accompanied by characteristic findings

General

vulvar dystrophy (vulvar disorder) mucocutaneous candidiasis (includes vulvovaginal candidiasis) vulvovaginitis

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 436-37
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17. American College of Physicians, Philadelphia 1998, 2012, 2015
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
  4. Journal Watch 24(18):141, 2004 Sobel JD, Wiesenfeld HC, Martens M, Danna P, Hooton TM, Rompalo A, Sperling M, Livengood C 3rd, Horowitz B, Von Thron J, Edwards L, Panzer H, Chu TC. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med. 2004 Aug 26;351(9):876-83. PMID: 15329425
  5. Prescriber's Letter 11(11):64 2004 Fluconazole (Diflucan) Prophylaxis for the Treatment of Recurrent Vulvovaginal Candidiasis Detail-Document#: 201104 (subscription needed) http://www.prescribersletter.com
  6. Journal Watch 24(21):162, 2004 Pirotta M, Gunn J, Chondros P, Grover S, O'Malley P, Hurley S, Garland S. Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: a randomised controlled trial. BMJ. 2004 Sep 4;329(7465):548. Epub 2004 Aug 27. PMID: 15333452 http://bmj.bmjjournals.com/cgi/content/full/329/7465/548
  7. Prescriber's Letter 17(8): 2010 CHART: Treatment of Complicated Vaginal Yeast Infections CHART: Treatment of Uncomplicated Vaginal Yeast Infections GUIDELINES: Infectious Diseases Society of America Guidelines for the Management of Candidiasis (2009 update) GUIDELINES: Sexually Transmitted Diseases Treatment Guidelines (2006) Detail-Document#: 260806 (subscription needed) http://www.prescribersletter.com
  8. Achkar JM, Fries BC. Candida infections of the genitourinary tract. Clin Microbiol Rev. 2010 Apr;23(2):253-73. Review. PMID: 20375352 Free PMC Article
  9. NEJM Knowledge+