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Wednesday, September 2, 2015

Vulvovaginal candidiasis

This is one of the most common genital infections and is caused by Candida albicans in around 80–92 per cent of cases. Other non-albican species like C. tropicalis, C. glabrata, C. krusei and C. parapsilosis can also cause similar symptoms, although sometimes more severe and recurrent. C. albicans is a diploid fungus and is a common commensal in the gut flora. It is important to confirm the diagnosis with a perineal and/or vaginal swab. Conditions such as contact dermatitis, allergic reactions and non-specific vaginal infections can present in a similar manner. Testing can be done with a Gram stain or wet film examination and direct plating on to fungal media. Further testing to type the species may be required in recurrent or very severe cases as some species such as C. krusei can be resistant to some of the imidazoles, such as fluconazole.

Pregnancy, high-dose combined oral contraceptive pill, immunosuppresion, broad spectrum antibiotics, diabetes mellitus, hormone replacement therapy and HIV-infected women have a higher predisposition to develop vulvovaginal candidiasis.

Up to 30–40 per cent of asymptomatic women may have C. albicans grown on a vaginal swab. These women do not need treatment even if they are pregnant. There is no evidence of any adverse effects in pregnancy to either the mother or the baby if treated with topical imidazoles. However, the oral imidazoles are contraindicated in pregnancy.

Women should be advised to avoid using any soaps, perfumes and synthetic underwear. The high-dose o estrogen combined oral contraceptive pill should be changed to a lower-dose pill. If there are persistent or recurrent symptoms, consideration should be given to change to a progesterone-only contraception. Check blood sugars to rule out undiagnosed diabetes mellitus and if present good glycaemic control should be the aim. Avoid recurrent courses of broad spectrum antibiotics. The treatment of vulvovaginal candidiasis can be based on whether the infection is uncomplicated, complicated or severe and recurrent.

Azoles/imidazoles are the mainstay of the treatment. They can either be used either as a local topical application (pessaries/creams) or oral preparations. There are several types of imidazoles with similar efficacy with a cure rate of over 80 per cent. The treatment is usually based on the preference of the physician, local availability and costs. The common imidazoles are clotrimazole, econazole and miconazole. Other antifungals, such as nystatin cream or pessary, can also be used. The medication can be taken as a single pessary treatment or a course of pessaries for a few days at a lower dose. The commonly prescribed medication is clotrimazole, which can be taken as single 500 mg pessary or a course of a 100 mg pessary over 6 days. Oral imidazoles, such as fluconazole, are given as a single dose at 150 mg or itraconazole 200 mg twice a day for 1 day. However, these are contraindicated in pregnancy.

There is no evidence to treat the asymptomatic male partner.

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