Vulvovaginal candidiasis (VVC) usually is caused by C. albicans but occasionally is caused by other Candida sp. or yeasts. Typical symptoms of Vulvovaginal candidiasis include pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar burning, dyspareunia, and external dysuria. None of these symptoms is specific for VVC.
An estimated 75% of women will have at least one episode of Vulvovaginal candidiasis, and 40%--45% will have two or more episodes. On the basis of clinical presentation, microbiology, host factors, and response to therapy, Vulvovaginal candidiasis can be classified as either uncomplicated or complicated. Approximately 10%--20% of women will have complicated Vulvovaginal candidiasis, suggesting diagnostic and therapeutic considerations.
Classification of vulvovaginal candidiasis (VVC)
- Sporadic or infrequent vulvovaginal candidiasis
- Mild-to-moderate vulvovaginal candidiasis
- Likely to be C. albicans
- Non-immunocompromised women
Complicated Vulvovaginal candidiasis
- Recurrent vulvovaginal candidiasis
- Severe vulvovaginal candidiasis
- Non-albicans candidiasis
- Women with uncontrolled diabetes, debilitation, or immunosuppression or those who are pregnant
Uncomplicated Vulvovaginal Candidiasis
Diagnostic Considerations in Uncomplicated VVC
A diagnosis of Candida vaginitis is suggested clinically by pruritus and erythema in the vulvovaginal area; a white discharge may be present. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either a) a wet preparation (saline, 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae or b) a culture or other test yields a positive result for a yeast species. Candida vaginitis is associated with a normal vaginal pH ( < 4.5). Use of 10% KOH in wet preparations improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae. Identifying Candida by culture in the absence of symptoms is not an indication for treatment, because approximately 10%--20% of women harbor Candida sp. and other yeasts in the vagina. Vulvovaginal candidiasis can occur concomitantly with STDs, and treatment of all pathogens present is warranted. Most healthy women with uncomplicated VVC have no precipitating factors. However, in a minority of women who have asymptomatic Candida colonization, antibiotic use precipitates VVC.
Treatment of Vulvovaginal Candidiasis
Short-course topical formulations (i.e., single dose and regimens of 1--3 days) effectively treat uncomplicated Vulvovaginal candidiasis. The topically applied azole drugs are more effective than nystatin. Treatment with azoles results in relief of symptoms and negative cultures in 80%--90% of patients who complete therapy.
- Butoconazole 2% cream 5 g intravaginally for 3 days
- Butoconazole 2% cream 5 g (Butaconazole1-sustained release), single intravaginal application
- Clotrimazole 1% cream 5 g intravaginally for 7--14 days
- Clotrimazole 100 mg vaginal tablet for 7 days
- Clotrimazole 100 mg vaginal tablet, two tablets for 3 days
- Clotrimazole 500 mg vaginal tablet, one tablet in a single application
- Miconazole 2% cream 5 g intravaginally for 7 days (over-the-counter [OTC] preparation)
- Miconazole 100 mg vaginal suppository, one suppository for 7 days (OTC preparation)
- Miconazole 200 mg vaginal suppository, one suppository for 3 days (OTC preparation)
- Nystatin 100,000-unit vaginal tablet, one tablet for 14 days
- Tioconazole 6.5% ointment 5 g intravaginally in a single application (OTC preparation)
- Terconazole 0.4% cream 5 g intravaginally for 7 days
- Terconazole 0.8% cream 5 g intravaginally for 3 days
- Terconazole 80 mg vaginal suppository, one suppository for 3 days
- Fluconazole 150 mg oral tablet, one tablet in single dose
Note: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom product labeling for further information.
Preparations for intravaginal administration of butaconazole, clotrimazole, miconazole, and tioconazole are available over-the-counter (OTC). Self-medication with OTC preparations should be advised only for women who have been diagnosed previously with VVC 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. Unnecessary or inappropriate use of OTC preparations is common and can lead to delay of treatment of other etiologies of vulvovaginitis that could result in adverse clinical outcomes.
Patients should be instructed to return for follow-up visits only if symptoms persist or recur within 2 months of onset of initial symptoms.
Management of Sex Partners
Vulvovaginal candidiasis is not usually acquired through sexual intercourse; treatment of sex partners is not recommended but may be considered in women who have recurrent infection. A minority of male sex partners may have balanitis, which is 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.
Allergy to or Intolerance of the Recommended Therapy. Topical agents usually cause no systemic side effects, although local burning or irritation may occur. Oral agents occasionally cause nausea, abdominal pain, and headache. Therapy with the oral azoles has been associated rarely with abnormal elevations of liver enzymes. Clinically important interactions might occur when these oral agents are administered with other drugs, including astemizole, calcium channel antagonists, cisapride, coumadin, cyclosporin A, oral hypoglycemic agents, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, trimetrexate, and rifampin.
National Guideline Clearinghouse