Recurrent vulvovaginal Candidiasis

1. Benha University Hospital, EGYPT
Aboubakr Elnashar

2. There are 150 candida species
C albicans is by far the most common, it
accounts for 80-90%
C glabrata is the second most common, it
accounts for 5-15%
C tropicalis (5%)
Other species eg C krusei, C guilliermondi
are rarely isolated
Aboubakr Elnashar

3. Colonization
Uncomplicated VVC:
1.Sporadic or infrequent
VVC
2.Mild or moderate VVC
3.Likely to be C. albicans
4.Non-immunocompromized
.
Aboubakr Elnashar

4. .Complicated VVC:
1.Recurrent VVC
2.Severe VVC: extensive vulvar erythema,
oedema, and excoriation, fissure formation.
Symptoms are correlated with the amount of
yeast in the vagina (Odds,1988)
3.Non-albicans VVC
4.Women with uncontrolled , DM, debilitation,
immunosuppression or those who are pregnant
Aboubakr Elnashar

5. Asymptomatic female should not
be treated even if the culture is
positive
Uncomplicated:
. Local (topical, intravaginal) antifungal:
Polyene: nystatin.
Azoles: clotrimazole, miconazole,
econazole, butoconazole, ticonazole,
terconazole.
Aboubakr Elnashar

6. •Both azoles & nystatin are fungistatic rather
than fungicidal.
•Nystatin is less effective than azole treatment. It
needs to be given for 14 days, but is indicated if
there is a possibility of non-albicans yeast
infection.
•Azoles resulted in higher rates of clinical &
mycologic cure (80-95%) than nystatin (&0-90%)
in non pregnant acute VVC.
•Short course (single dose & regimens of 1-3
days)effectively treat uncomplicated VVC.
Aboubakr Elnashar

7. 2. Oral antifungal: more effective against non-
albican species.
. Ketoconazole (Nizoral ,200mg)
Dose: 1X2X5
. Itraconazole (Sporanox, 100 mg )
Dose: 2X2X1
. Fluconazole (Diflucan, Alkanazol,150 mg)
Dose : 1 tab single dose
Aboubakr Elnashar

8. Oral or vaginal antifungal (Cochrane libarary, 2001)
.No differences exist in terms of the relative
effectiveness (mycological & clinical cure ) of antifungals
oral & vaginal route for uncomplicated vaginal
candidiasis. Both routes achieved clinical cure in over
80% of subjects.
.The oral route is the preferred route by the patient. The
decision to prescribe oral or vaginal depends on safety,
cost, effectiveness, & patient preference. Oral
preparation is more expensive & associated with more
systemic side effects than vaginal route.
Vaginal route is first line of therapy (Reef, 1993)
Aboubakr Elnashar

9. Causes of clinical failure:
1.Vaginitis due to other causes.
2.Undiagnosed urogenital infection.
3.Chemical irritants: perfumed products, detergents
4.Physical damage: sexual intercourse, tampons
Causes of therapeutic failure:
1.Resistance to the antifungal
2.Presence of species out side the spectrum of the
antifungal. Non albicans C are associated with vaginitis
& are more resistant to conventional antifungal therapy.
C glabrata & C Krusei are resistant to fluconazole &
itraconazole (Rex,2000)
Aboubakr Elnashar

10. •Complicated VVC
Recurrent VVC
Define:
•4 or more episodes/Y.
•Reappearance of C in the vagina of a patient,
who was cured, & may be either
Relapse, (due to re-growth of a previously
undetected residual population of C.) or
Re-infection (the vagina is re-inoculated from
some extravaginal source).
Aboubakr Elnashar

11. Prevalence:
5% in family planning clinic & 10% in antenatal clinic. No
apparent predisposing or underlying conditions in most
cases.
Pathogenesis:
Non-albicans are found in 30% of cases
Source:
1.Vaginal inoculation: most common
Intestinal reservoir theory
Sexual transmission
2.Vaginal recurrence
Aboubakr Elnashar

12. Although iron deficiency anaemia has been suggested
as a cause of recurrent VVC, there is no evidence to
support this.
DM is rarely newly diagnosed.
Allergic rhinitis/hayfever may be immunologically linked
with RVVC.
Mechanisms:
1.Increased C virulence
2.Host factors
Decreased secretory local immunity
IgE mediated hypersensitivity reaction
Loss of lactobacilli protective effect
Aboubakr Elnashar

13. Treatment:
.Vaginal culture should be obtained to confirm clinical
diagnosis & to identify unusual species, including non-
albicans species, particularly C glabrata (not form
hyphae).
1. Longer duration of initial therapy
a.7-14 days of topical therapy or
b. 150-mg, oral dose of fluconazole repeated 3 days
later
to achieve mycologic remission before initiating a
maintenance therapy.
In contrast to severe VVC, increasing the length of
therapy by up to 1 week, for example by adding a
second dose of fluconazole, does not improve response
(Sobel et al, 2001)
Aboubakr Elnashar

14. 2. Maintenance (Suppressive) therapy for 6 months:
Clotrimazole (500-mg dose vaginal sup once weekly)
Fluconazole (100-150 mg once weekly)
Itraconazole (400 mg once monthly or 100 mg once
daily)
The frequency of therapy depend on frequency of
attacks (White & Vanthuyne,2002):
> 1/month: weekly doses, 1/month: monthly doses.
Twice-monthly doses are usually adequate: D8 & D 18
of the cycle just before the hormonal peaks
Aboubakr Elnashar

15. Treatment of the husband: controversial
Treatment of the predisposing factors:
Nitrofurantoin & nalidixic acid are recommended for UTI
since they give low tissue levels.
Psychosexual problems are common in RVVC, use of
vaginal lubricants is important
Relapse: 40% of women, the cycle of suppressive
therapy can be continued indefinitely (Sobel et al,1992)
Aboubakr Elnashar

16. Non-albicans VVC
1. First line therapy: Longer duration therapy with a
non-fluconazole azole is recommended i.e; Nystatin
pessaries once or twice nightly for 14 days.
2. 2nd
line treatment (If recurrence occurs) 600 mg of
boric acid in gelatin capsule vaginally once daily for 2
weeks.
Aboubakr Elnashar

17. 3.The final resort: Topical 4% flucytosine, the only
fungicidal agent, & amphotericin B in lubricating gjelly
for 14 nights
4. If non-albicans VVC continues to recur, a
maintenance regimen of 100,000 units of nystatin
delivered vaginally.
5. Intravaginal painting with gentian violet & oral
progesterone ( little information is available)
Aboubakr Elnashar

18. Benha University Hospital, EGYPT
Aboubakr Elnashar