Candidiasis, Vulvovaginal

Background

Vulvovaginal candidiasis is a yeast infection caused by several types of Candida, typically Candida albicans. This disease is common in all women, but may occur more frequently and more severely in immunocompromised women.

Although refractory vaginal Candida infections by themselves should not be considered indicators of HIV infection, they may be the first clinical manifestation of HIV infection and can occur early in the course of disease (at CD4 counts of >500 cells/µL). The frequency of vaginal candidiasis tends to increase as CD4 counts decrease; however, this may be attributable in part to increased use of antibiotics among women with advanced HIV infection.

Risk factors for candidiasis include diabetes mellitus and the use of oral contraceptives, corticosteroids, or antibiotics.

S: Subjective

The patient may complain of itching, burning, or swelling of the labia and vulva; a thick white or yellowish vaginal discharge; painful intercourse; and pain and burning on urination.

The most important elements in the history include the following:

  • Type and duration of symptoms
  • Previous vaginal yeast infection
  • Oral contraceptive use
  • Recent or ongoing broad-spectrum antibiotic therapy
  • Recent corticosteroid therapy
  • Sexual exposures (to evaluate for sexually transmitted diseases)
  • Diabetes history
  • Cushing syndrome
  • Obesity
  • Hypothyroidism
  • Pregnancy
  • Use of douches, vaginal deodorants, or bath additives

O: Objective

Perform a focused physical examination of the external genitalia, vagina, and cervix. This may reveal inflammation of the vulva with evidence of discharge on the labial folds and vaginal opening. Speculum examination usually reveals a thick, white discharge with plaques adhering to the vaginal walls and cervix. Bimanual examination should not elicit pain or tenderness and otherwise should be normal.

A: Assessment

Rule out other causes of vaginal discharge and pruritus:

  • Bacterial vaginosis
  • Atrophic vaginitis
  • Chemical or mechanical causes
  • Trichomoniasis
  • Gonorrhea, chlamydia, and other sexually transmitted diseases
  • Scabies
  • Pediculosis

P: Plan

Diagnostic Evaluation

A presumptive diagnosis is made on the basis of the clinical presentation and potassium hydroxide (KOH) preparation:

  • Perform microscopic examination of a KOH preparation of vaginal secretions. This usually reveals pseudohyphae and Candida spores (presumptive diagnosis).
  • Definitive diagnosis rarely is needed, but may be made by analysis of a culture of vaginal secretions; this may be useful if azole-resistant or non-albicans species are suspected.
  • In the presence of urinary tract symptoms (beyond external vulvar burning), perform urinalysis, culture, or both on a clean-catch urine specimen.
  • Consider testing for gonorrhea and chlamydia in patients with a history of possible sexual exposure.

Treatment

Uncomplicated infections

Topical medications

  • Prescribe topical vaginal antifungal agents in the form of cream or suppositories, including the following: butoconazole, clotrimazole, miconazole, nystatin, terconazole, and tioconazole. Treat for 3-7 days and offer refills depending on the time to the next scheduled clinic visit. The creams also may be used on the vulva for treatment of pruritus.

Note that the mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise the patient to use alternative methods to prevent HIV transmission or conception, or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.

Oral medications

Preferred

  • Fluconazole 150 mg PO, single dose (see "Treatment notes," below)

Alternative

  • Itraconazole oral solution 200 mg PO QD for 3-7 days (see "Treatment notes," below)

Complicated infections

Severe or recurrent candidiasis

Severe or recurrent candidiasis is defined as four or more episodes within 1 year. Consider the following treatments:

  • Fluconazole 100-200 mg PO QD for ≥7 days (see Treatment notes," below)
  • Topical therapy as described above, for ≥7 days

For severe cases that recur repeatedly, secondary prophylaxis can be considered (e.g., fluconazole 150 mg PO once weekly).

Treatment notes

  • Systemic azole drugs should not be used during pregnancy, and women taking azoles should use effective contraception. Topical azoles are recommended for the treatment of pregnant women.
  • Resistance to azole medications may develop, especially with prolonged use of oral agents.
  • Avoid ketoconazole: Case reports have associated ketoconazole with a risk of fulminant hepatitis (1 in 12,000 courses of treatment with oral ketoconazole). Experts agree that the risks may outweigh the benefits for women with vulvovaginal candidiasis. Ketoconazole interacts with many other drugs, including some antiretroviral drugs.

Potential ARV Interactions

There may be significant drug-drug interactions between certain systemic antifungals (particularly itraconazole, voriconazole, and posaconazole) and ritonavir-boosted protease inhibitors (PIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), elvitegravir/cobicistat, or maraviroc. Some combinations are contraindicated and others require dosage adjustment of the ARV, the antifungal, or both. Check for adverse drug interactions before prescribing. For example, voriconazole use is not recommended for patients taking ritonavir-boosted PIs, and dosage adjustment of both voriconazole and NNRTIs may be required when voriconazole is used concurrently with NNRTIs. See relevant tables in the U.S. Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, or consult with an expert.

Patient Education

  • Advise patients to wash external genitals daily with a fresh washcloth or water-soaked cotton balls and to wipe the vulva and perirectal area from front to back after toileting. Women should not use baby wipes on inflamed vulval tissue because they may increase irritation.
  • Women should avoid the use of perfumed soaps, bubble baths, feminine hygiene or vaginal deodorant products, and bath powders.
  • Advise women not to douche.
  • Women should wear cotton underwear and avoid tight, constrictive clothing, particularly pantyhose.
  • If patients are prescribed medication for vaginal candidiasis, they should take the medication exactly as prescribed and finish the medicine even during a menstrual period.
  • Women who continue to have symptoms can purchase miconazole (e.g., Monistat) or clotrimazole (e.g., Gyne-Lotrimin) vaginal cream over the counter. Advise patients to start using these as soon as symptoms return and to contact the clinic if symptoms worsen while they are taking these medicines.
  • Women taking oral fluconazole, ketoconazole, or other azoles must avoid pregnancy. Some birth defects have been reported.
  • The mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise patients to use alternative methods to prevent HIV transmission or conception or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.
  • Sex toys, douche nozzles, diaphragms, cervical caps, and other items can reinfect patients if not properly cleaned and thoroughly dried after use.
  • Some studies have suggested that eating yogurt with live cultures (check labels) can reduce the occurrence of vaginal yeast infections.

References

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Abbreviations for Dosing Terminology

BID
twice daily
BIW
twice weekly
IM
intramuscular (injection), intramuscularly
IV
intravenous (injection), intravenously
PO
oral, orally
Q2H, Q4H, etc.
every 2 hours, every 4 hours, etc.
QAM
every morning
QD
once daily
QH
every hour
QHS
every night at bedtime
QID
four times daily
QOD
every other day
QPM
every evening
TID
three times daily
TIW
three times weekly