Vulvovaginal Candidiasis

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Candidiasis is usually endogenous in origin and is not considered to be a sexually transmitted infection.
Causative species:

  • 80-90% Candida albicans.
  • Non-albicans species - e.g C. glabrata

Risk factors for candida includeiabetes Pregnancy:

  • Antibiotic use 
  • Immunosuppressive therapy
  • HIV 
  • Damaged skin eg herpes vulvitis, dermatitis, 
  • Potent topical corticosteroids

The combined oral contraceptive pill does not usually predispose to candidiasis, although higher oestrogen doses in some women will. If so consider a lower dose of oestrogen. The evidence for progesterone only methods is not strong.

DIAGNOSIS

Diagnosis generally should not be made in the absence of symptoms; positive culture alone may only reflect fungal colonization. Positive microscopy increases the likelihood of acute infection.

Take:
Vaginal swab for microscopy. Culture only if needed for speciation or micro negative but symptoms suggest candida. Swab areas of dermatitis on the vulva, especially fine scale or erosion.

HSV PCR if erosions or fissures are present. .
pH of vaginal discharge (not cervical mucus) remains normal at <4.5.
pH will be higher if semen, creams or blood are present. It is usually high post menopausally.
Candida and bacterial vaginosis can occur together. Polymorphs will usually be seen in this case, and the pH usually reflects the BV. Treatment for BV may precipitate or prolong the candida, therefore advise longer treatment duration.

Gram stain sensitivity is 60-70%. Vaginal wet preparation is not necessary for candida diagnosis. However, it is needed to diagnose trichomonas and for the amine test in the diagnosis of BV.

Culture will be positive in 30-50% of cases with negative microscopy. Culture is commonly positive in asymptomatic women.

Recent antifungal treatment in the previous 4 weeks can suppress growth in culture medium and give false negative results.

Exclude co-morbidities:

  1. dermatoses, 
  2. vulval pain syndromes are commonly associated with recurrent symptoms. Burning after sex can be an early symptom of provoked vulvodynia.

Instruct all patients regarding good skin care (refer to Genital skin care Fact sheet).
Alternative diagnoses if negative M and C.
Pain syndromes, especially with burning after sex, can mimic symptoms of candidiasis.

MANAGEMENT OF CANDIDA ALBICANS

Acute vulvovaginal candida
All topical and oral azole therapies give cure rates of 80-95% in non-pregnant women. Topical azoles may work faster than oral azoles, but can be associated with contact irritation. Nystatin preparations give cure rates of 70-90% and may be less irritating than clotrimazole, but need longer duration of treatment Single dose topical treatments have a slightly higher failure rate
Treatment options:

  • Clotrimazole 100mg pessary or vaginal cream for 6 nights.
  • Clotrimazole 200mg pessary for 3 nights. 
  • Clotrimazole 500mg pessary single dose.
  • Nystatin vaginal cream (100,000U) for 14 nights or pessary twice daily for 7 days. 
  • Miconazole 100mg vaginal cream or pessary for 6 nights.
  • Fluconazole 150mg orally as a single dose* – repeat in 3 days if severe. 
  • Consider additional vaginal azole for the first few days if severe because it may work faster than oral alone
  • If severe vulvitis add 1% hydrocortisone with clotrimazole (hydrozole) until the soreness/itch settles. Consider repeat oral dose of fluconazole in one week.

Add antiviral if suspect coexistent HSV (candida vulvitis can be erosive)

Pregnancy: FLUCONAZOLE IS CATEGORY D.

*Oral azoles contraindicated in pregnant women. Use topical therapy possibly for a longer duration i.e. 12-14 days as lower response rates and more frequent relapses can occur in pregnancy. 

Recurrent vulvovaginal candida
Defined as 4 or more mycologically proven episodes per year. Occurs in 5% of healthy women.
Evidence suggests that some women develop localized hypersensitivity to yeasts that interferes with effective immune response and predisposes to recurrence. It is the same vaginal yeast population that recurs and is usually different to GI tract species.
There is no evidence that treating the partner reduces recurrence – he or she should be treated if symptomatic. Case reports suggest that oral sex with a partner who uses inhaled corticosteroids and has oral candida may predispose to RVVC in the other partner.

Treatment is aimed at suppressing growth sufficiently so that host immunity will be able to then control symptoms.
Nystatin will not be effective for RVVC if given orally as it is not absorbed from the gastrointestinal tract. The subtype of candida in RVVC is usually different to the subtype cultured from the rectum.

All suppressive regimens should be used at some level for about 6 months. Trials have suggested 90% effectiveness with fluconazole 150mg weekly. Relapse after 6 months usually is less frequent but women should be warned to expect an episode. Suppression can be resumed or a double duration of standard treatment used and response evaluated.

Induction regimens

Oral therapy:
150mg fluconazole (may repeat in 3 days or add topical azole as above) then weekly for 4-6 weeks. Follow with maintenance regimen.
Topical:
Nystatin 100,000U intravaginally nightly for 28 days (nystatin is less irritating than other topical agents and less likely to lead to contact dermatitis). Vaginal azole for 2 weeks, plus hydrozole if vulvitis twice daily or 1% hydrocortisone ointment twice daily.
Review at one month and repeat micro and culture if still symptoms.

Maintenance regimens

Fluconazole:
150mg weekly for 2-3 months (less if very good response, occasionally twice weekly is needed) then taper to fortnightly and monthly as tolerated to a total of 6 months. Alternatively, the dose can be reduced to 100mg, then 50mg, weekly if response is good with 150 mg. There is no RCT as yet to support other dose regimens. Clinical experience with lower doses and longer dosing intervals has shown effectiveness.

Nystatin or azole cream or pessary:
3 times a week and tapering to 2 times a week then once weekly over a 6 month period
Breakthrough VVC may occur during tapering and some patients need to stay on the higher or more frequent doses for the 6 month period.

50% of women experience relapse within 6 months of completing therapy – longer term suppression may be needed and is safe. LFTs are generally not required with long term fluconazole at this low and intermittent dose

Recommend avoiding soap and use emollients for prevention of dermatitis

More than 6 months treatment is often needed, and does not always imply a serious underlying disorder. Occasionally women will need several years of suppressive treatment.

MANAGEMENT OF CANDIDA GLABRATA and other non- albicans species
Non albicans species are not always symptomatic.
They can be selected out after frequent antifungal treatments.
Fungal sensitivities can be requested if there is treatment failure for candida.
Symptoms may also be due to coexistent dermatitis or a vulval pain syndrome. These can be subtle and second opinion is often recommended.

First Line therapy
  1. Standard C. albicans treatments should be considered.
    If standard treatments have failed, higher dose azoles or nystatin for a longer duration, 2 weeks as a minimum, can be considered. A MSHC discussion group recommended twice daily topical antifungals of 2 classes for 14 days in order to address resistance problems
    otherwise: 
  2. Boric acid pessaries 600mg VAGINALLY nightly 10-14 days (avoid in pregnancy). Success rate is estimated at 70%. Available from pharmacy at MSHC and selected compounding pharmacies - poisoning/toxicity must be discussed with patient if accidentally ingested orally. 
  3. Amphotericin B oral lozenges VAGINALLY (Category B3), twice a day for 7 -10 days. Warn that it is messy. Intravaginal use has been reported in the literature, either prepared in a cream base or as oral 10mg lozenges - dose and duration not established. It is cheap for patients, probably as effective as boric acid but will stain underwear.

Fluconazole may be ineffective for C. glabrata but could be tried. C. krusei is generally resistant to fluconazole. A common regimen is twice daily for two weeks, then taper to x2-3 per week.
Yeast sensitivity to antifungals commonly includes testing against amphotericin B but not against boric acid.
Other therapy

Itraconazole is rarely needed.

Ketoconazole is no longer available due to toxicities.

Maintenance therapy

There are no evidence based guidelines for maintenance therapy for recurrent symptomatic non-albicans infections. Studies comparing different medications are not available. Always look carefully for a predisposing factor. Consider:

  • Boric acid pessaries PV 3 times weekly for 2 weeks then weekly for 2 weeks then re-evaluate
  • Amphotericin B lozenges PV x2-3 per week, OR
  • Nystatin cream 3 times weekly.


Duration of suppression needs to be individualized and can range from 1-6 months depending on past history, therapy used and patient preference. Relapses are common but usually less frequent after long term treatment. Discuss treatment options for relapses before ceasing suppression.

REMEMBER - poor control of symptoms may reflect a pain syndrome and/or a subtle dermatitis.

Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Last Updated Mar 2017