Vulvovaginal Candidiasis

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This is a yeast infection of the vagina vulva.

Cause

  • Candida albicans: most common
  • dubliniensis; C. kefyr; C. krusei; C. glabrata; C. guilliermondii; C. parapsilosis; C. tropicalis: these are increasingly identified as causes of non-albicans candidiasis.

Classification of vulvovaginal candidiasis (VVC)

Uncomplicated vulvovaginal candidiasis

- Sporadic or infrequent  VVC

- Mild-to-moderate VVC

- Likely to be Candida albicans present in women who are not immunocompromised

Complicated

- Recurrent VVC

- Severe VVC

- Non-albicans candidiasis

- Likely  in women with diabetes,  immunocompromised conditions (e.g. HIV infection), debilitation, or immunosuppressive therapy (e.g. corticosteroids)
  • Vaginal ulcers
  • Abnormal vaginal discharge
  • Vaginal itching
  • Painful sexual intercourse dyspareunia
  • Dysuria

Differential diagnosis

  • Other causes of vaginal discharge (see Gonorrhoea)

Investigations

  • Positive KOH examination
  • Culture of vaginal discharge

Treatment objectives

  • Cure the infection
  • Prevent recurrence

Pharmacological treatment3

Recommended treatment for Uncomplicated VVC

Vaginal and vulval candidiasis

Clotrimazole 1% or 2% cream

Adult:

Apply to anogenital area 2-3 times a day

Vaginal candidiasis

Clotrimazole 10% intravaginal cream

Adult: 5 g per dose via applicator intravaginally at night. Repeat once if necessary

OR

Miconazole vaginal capsules

Child or Adult:

One ovule to be inserted intravaginally at night.

Dose may be repeated if required

OR

Miconazole 2% cream

5 g intravaginally twice daily for 7 days or once daily for 10-14 days

Apply cream to anogenital area twice daily

Caution:

  • Avoid applicators in young girls who are not sexually active unless there is no alternative
  • Avoid in acute porphyria

AND

Fluconazole oral

150 mg single dose 

Recommended treatment for Complicated VVC

Recurrent VVC

1st Line Treatment

Fluconazole oral

100 mg or 150 mg or 200 mg weekly for 6 months

Maintenance therapy

Fluconazole oral

100 mg or 150 mg or 200 mg every third day for a total of 3 doses [day 1, 4, and 7]

Severe VVC

Fluconazole oral

150 mg in two sequential oral doses (72 hours after initial dose) is recommended

Immunocompromised host

Fluconazole oral

100 mg or 150mg or 200 mg every third day for a total of 3 doses [day 1, 4, and 7]

Pregnant women

Give only topical azole therapies, applied for 7 days

Clotrimazole 1% or 2% cream

Apply to anogenital area 2-3 times a day

OR

Miconazole vaginal capsules

Adult or child:

One ovule to be inserted intravaginally at night.

Dose may be repeated if required

Miconazole 2% cream

5 g intravaginally twice daily for 7 days on once daily for 10-14 days

Apply cream to anogenital area twice daily

Caution:

  • Avoid applicators in young girls who are not sexually active unless there is no alternative
  • Avoid in acute porphyria

HIV infected Patients

Fluconazole oral

200 mg weekly 

Prevention

  • Reduce or eliminate predisposing factors, after defecation cleaning should be done backwards to prevent contamination of the vulva and vagina 

Referral

  • If no improvement refer for specialist care

[1] CDC guidelines