Guideline: Vulvovaginal Candidosis (AWMF 015/072), S2k (excluding chronic mucocutaneous candidosis)

Abstract

The oestrogenised vagina is colonised by Candida species in at least 20% of women; in late pregnancy and in immunosuppressed patients, this increases to at least 30%. In most cases, Candida albicans is involved. Host factors, particularly local defence mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and oestrogens influence the risk of candidal vulvovaginitis. Non-albicans species, particularly Candida glabrata, and in rare cases also Saccharomyces cerevisiae, cause less than 10% of all cases of vulvovaginitis with some regional variation; these are generally associated with milder signs and symptoms than normally seen with a C. albicans-associated vaginitis. Typical symptoms include premenstrual itching, burning, redness and odourless discharge. Although itching and redness of the introitus and vagina are typical symptoms, only 35-40% of women reporting genital itching in fact suffer from vulvovaginal candidosis. Medical history, clinical examination and microscopic examination of vaginal content using 400× optical magnification, or preferably phase contrast microscopy, are essential for diagnosis. In clinically and microscopically unclear cases and in chronically recurring cases, a fungal culture for pathogen determination should be performed. In the event of non-C. albicans species, the minimum inhibitory concentration (MIC) should also be determined. Chronic mucocutaneous candidosis, a rarer disorder which can occur in both sexes, has other causes and requires different diagnostic and treatment measures. Treatment with all antimycotic agents on the market (polyenes such as nystatin; imidazoles such as clotrimazole; and many others including ciclopirox olamine) is easy to administer in acute cases and is successful in more than 80% of cases. All vaginal preparations of polyenes, imidazoles and ciclopirox olamine and oral triazoles (fluconazole, itraconazole) are equally effective (Table ); however, oral triazoles should not be administered during pregnancy according to the manufacturers. C. glabrata is not sufficiently sensitive to the usual dosages of antimycotic agents approved for gynaecological use. In other countries, vaginal suppositories of boric acid (600 mg, 1-2 times daily for 14 days) or flucytosine are recommended. Boric acid treatment is not allowed in Germany and flucytosine is not available. Eight hundred-milligram oral fluconazole per day for 2-3 weeks is therefore recommended in Germany. Due to the clinical persistence of C. glabrata despite treatment with high-dose fluconazole, oral posaconazole and, more recently, echinocandins such as micafungin are under discussion; echinocandins are very expensive, are not approved for this indication and are not supported by clinical evidence of their efficacy. In cases of vulvovaginal candidosis, resistance to C. albicans does not play a significant role in the use of polyenes or azoles. Candida krusei is resistant to the triazoles, fluconazole and itraconazole. For this reason, local imidazole, ciclopi...

Safe and pragmatic use of sodium–glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement

“…The diagnosis of vulvovaginitis is made through history, physical examination, and simple laboratory tests. [128129] For the diagnosis of balanitis and balanoposthitis, a detailed history and physical examination is sufficient; biopsy is rarely necessary. [130] Local application of antifungal creams and powders can prove to be an effective treatment.…”

Extracellular proteinases of Candida species pathogenic yeasts

“…Indeed, no infectious symptoms are generally observed in healthy persons. In individuals with weakened immunity, Candida yeasts can cause annoying and painful superficial infections, such as oral thrush, cutaneous candidiasis or candidal vulvovaginitis . In severely ill and immunocompromised persons, including hospitalized patients after surgical treatment, organ transplantation or anticancer therapy, disseminated, multi‐organ, and systemic candidiasis often develops and is associated with high morbidity and mortality …”

Comparison of two long‐term gestagen regimens in the management of recurrent vulvovaginal candidiasis: A pilot study

“…2 Candida seems to be very well adapted to main conditions of vaginal environment including acidic pH and fluctuation of sexual hormone levels which can modulate the processes associated with transition between yeast and pseudo/mycelial morphology. [6][7][8] Restoration of normal physiological conditions in the vagina including of hormonal milieu has become the background for gestagen treatment of RVVC patients as an alternative approach to the management of the refractory infection. 9 Our previous results supported idea that one of a possible cause of RVVC is sexual hormonal level imbalance between oestrogens and gestagens.…”