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% is due to Candida albicans.
  • Non-albicans species - e.g C. glabrata

Risk factors for candida includeiabetes Pregnancy 

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

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:

  1. Vaginal swab for microscopy. Culture only if needed for speciation or if microscopy is negative but symptoms suggest candida. Swab areas of dermatitis on the vulva, especially fine scale or erosions.
  2. HSV PCR if erosions or fissures.
  3. pH of vaginal discharge (not cervical mucus) remains normal at <4.5. pH will be higher if water, 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 and reflects the commensal status.

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

Exclude co-morbidities:

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

Instruct all patients regarding good skin care and especially cease soap and cease daily panty liners (refer to Genital skin care Fact sheet).

REMEMBER: Pain syndromes, 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.. Longer or repeat treatments may therefore be needed. 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 with fluconazole 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.

Pregnancy: FLUCONAZOLE IS CATEGORY D.

*Oral azoles are 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 candidiasis (RVVC)
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 responses 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 sometimes predispose to RVVC in the other partner.

RVVC is a common trigger of chronic vulval pain (vulvodynia) and needs to be controlled.

Treatment is aimed at suppressing growth sufficiently so that host immunity will then be able to control symptoms.

Oral nystatin will not be effective for RVVC 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 the response evaluated.

Induction regimens

  1. 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. OR
  2. 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) plus 1% hydrocortisone ointment twice daily if there is associated dermatitis.. OR 
  3. 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

  1. Fluconazole 150mg weekly for 2-3 months (less if very good response, but 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, , weekly then tapered 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. OR 
  2. 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 or longer.

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 as the dose is low.

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 reduce candida albicans.
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 chould be considered.
    If standard treatments have failed, higher dose azoles or nystatin for a longer duration - 2 weeks as a minimum. A MSHC discussion group recommended twice daily topical antifungals of 2 classes for 14 days in order to address resistance problems – can be considered, 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.
    If effective initially but relapses occur, consider longer term treatment for some months. Eg x2-3 per week.
    Yeast sensitivity to antifungals commonly includes testing against amphotericin B but not against boric acid
  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. Longer term maintenance may be needed if relapses occur, eg twice per week as for boric acid.

Fluconazole may be ineffective for C. glabrata but could be tried. C. krusei is generally resistant to fluconazole

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 2-4 weeks then re-evaluate
  • Amphotericin B lozenges PV x2-3 per week, OR
  • Nystatin cream or pessary 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 Jun 2017