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Candida species are the second most common cause of infectious vaginitis.20 Prevalence data for vulvovaginal candidiasis vary because the disease is not reportable, many women self-medicate with over-the-counter preparations, and as many as half the women in whom candidiasis is diagnosed also have other conditions.20 The Centers for Disease Control and Prevention estimates that 75% of women will have at least one episode of vulvovaginal candidiasis in their lifetime.1
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The organism is isolated in up to 20% of asymptomatic, healthy women of childbearing age, some of whom are celibate. Some women remain entirely asymptomatic despite being heavily colonized with Candida species.
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Vulvovaginal candidiasis is rare in nonestrogenized premenarchal girls but does occur and is common under 2 years of age. Consider undiagnosed juvenile diabetes or other forms of immunosuppression if Candida is diagnosed in a toilet-trained child.4 Incidence decreases after menopause unless replacement estrogen is being used, which further emphasizes the hormonal dependence of the infection.
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Candidiasis can be classified as either an uncomplicated or complicated infection. Uncomplicated infections are sporadic, produce mild to moderate symptoms, are the result of Candida albicans, and occur in the nonpregnant, immunocompetent host. Complicated infections are recurrent (four or more infections per year), produce severe symptoms or findings, are the result of suspected or proven non-albicans candidiasis, and occur in an abnormal host (women who have uncontrolled diabetes, debilitation, or immunosuppression, or are pregnant). Approximately 10% to 20% of women have complicated disease. Recurrent vulvovaginal candidiasis occurs in <5% of women.1,21
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C. albicans strains account for 85% to 92% of Candida organisms isolated from the vagina. Candida glabrata and Candida tropicalis are the most common non-albicans strains and are often more resistant to conventional therapy.
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Candidal organisms gain access to the vaginal lumen and secretions predominantly from the adjacent perianal area. Candidal organisms must first adhere to the vaginal epithelial cells for colonization to take place, and C. albicans adheres in greater numbers than other species.
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The growth of Candida is held in check by the normal vaginal flora, and symptoms of vaginitis usually occur only when the normal balance is upset. Increased colonization by Candida resulting in subsequent symptomatic infection may be caused by conditions that (1) inhibit the growth of normal vaginal flora, particularly Lactobacillus species (e.g., systemic antibiotics); (2) diminish the glycogen stores in vaginal epithelial cells (e.g., diabetes mellitus, pregnancy, oral contraceptive use, and hormonal replacement therapy); or (3) increase the pH of vaginal secretions (e.g., menstrual blood or semen). Factors that favor increased rates of vaginal colonization include pregnancy, oral contraceptive use, uncontrolled diabetes mellitus, and frequent visits to sexually transmitted infection clinics (perhaps as a result of antimicrobial therapy). This infection is not considered a sexually transmitted infection, although it can be transmitted by sexual intercourse. The wearing of tight-fitting, particularly synthetic, undergarments may also contribute to the problem because of increased temperature. Although all of these factors are thought to be associated with symptomatic disease, there is poor evidence to prove that any of them is causative.20 Evidence supporting an association between antibiotic use and vulvovaginal candidiasis is limited. However, antibiotics are thought to increase the risk of vulvovaginal candidiasis by killing endogenous normal flora.
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Clinical symptoms include leukorrhea, severe vaginal pruritus, external dysuria, and dyspareunia. Vaginal pruritus is the most common and specific symptom. Complaints of discharge vary from little to copious white vaginal discharge. Symptoms vary in severity, but exacerbation is frequently seen in the week prior to menses or with coitus, perhaps because these factors cause the pH to become more alkaline. Odor is unusual and, if present, favors a diagnosis of bacterial vaginosis rather than candidiasis.
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Gynecologic examination may reveal vulvar erythema and edema, vaginal erythema, and discharge. Discharge varies from none to watery to homogeneously thick and "cottage cheese–like." Discharge often adheres to the vaginal walls.
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The diagnosis is confirmed with a normal vaginal pH (4.0 to 4.5) and visualization of budding yeast and pseudohyphae on slide preparation of vaginal secretions (Figure 102–2). The sensitivity of microscopic examination using a sample prepared with normal saline is only 40% to 60%. Adding two drops of 10% potassium hydroxide to the vaginal secretions dissolves the vaginal epithelial cells while leaving yeast buds and pseudohyphae intact. This increases the sensitivity of microscopic examination to 80% and yields almost 100% specificity. Empiric treatment is suggested for symptomatic patients with negative findings on microscopic examination if Candida cultures cannot be obtained.1
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Recommended treatment regimens are listed in Table 102–5. Therapy regimens are effective in treating over 80% of cases of uncomplicated vaginal candidiasis. Topically applied azole drugs are more effective than nystatin, with relief of symptoms in 80% to 90% of patients who complete treatment. Consider patient preference because creams, lotions, sprays, vaginal tablets, suppositories, and coated tampons are all equally efficacious.22
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The azole drugs are all available over the counter in treatment regimens of 1, 3, or 7 days. Uncomplicated vulvovaginal candidiasis responds to all azoles, including single-dose therapy.23 Other than initial burning and irritation, side effects of topical agents are unusual.
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Single-dose treatment with oral fluconazole is as effective as topical therapy in the treatment of uncomplicated vulvovaginal candidiasis. Patient preference should be considered, because oral therapy is often more convenient, although insurance and cultural variables can influence preference.24 Oral treatment may occasionally cause GI symptoms, headache, and rash.25 Ketoconazole can cause liver toxicity, and therefore, it as been removed from many formularies. The oral azoles can interact with a variety of other medications, including astemizole, calcium channel antagonists, cisapride, warfarin, cyclosporine A, oral hypoglycemic agents, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, trimetrexate, and rifampin.
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Sexual partners should not be treated unless the woman has frequent recurrences.
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Self-medication is sometimes advised in women with recurrence of previously diagnosed vulvovaginal candidiasis; however, studies demonstrate poor ability to accurately self-diagnose candidiasis even with a prior history of the disease.5,26 Therefore women who fail to respond to over-the-counter therapy or have recurrence within 2 months should be evaluated by a physician.
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The treatment of complicated vulvovaginal candidiasis (both severe and recurrent cases) requires longer duration of therapy with topical and oral azoles or alternative therapies. In severe cases, consider treating with a topical azole for 7 to 14 days or treatment with oral fluconazole, 150 milligrams on days 1 and 3 for a total of two doses. In cases of recurrence, consider treating with a topical azole for 7 to 14 days or fluconazole, 100, 150, or 200 milligrams on days 1, 4, and 7 for a total of three doses.1,25,26
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CANDIDIASIS COMPLICATIONS
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Vaginal and microscopic examinations should be performed if symptoms persist or recur within 2 months, and precipitating factors, such as high blood glucose levels, should be controlled. However, most women with recurrences do not have obvious precipitating causes. Vaginal cultures should be obtained to confirm clinical diagnosis but also to indentify any unusual species such as C. glabrata. Azoles are not very effective in treating vaginitis caused by C. glabrata.
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Management of women with frequent recurrence is aimed at control with a long-term suppressive prophylactic regimen, rather than cure. The reason that some women, many of whom have no underlying pathology, experience frequent recurrences of infection with resulting morbidity is not fully understood. Current views suggest that local vaginal immune mechanisms may be responsible for frequent relapses. Maintenance regimens with oral fluconazole (100-, 150-, or 200-milligram doses weekly for 6 months) are the first line of treatment.1