Vulvovaginal Candidiasis

Background

• Vulvovaginal candidiasis is a common cause of vulvovaginitis due to the growth of Candida albicans or other Candida species. The estimated lifetime prevalence of vulvovaginal candidiasis among all women is about 70%.
• Vulvovaginal candidiasis may be idiopathic, or secondary to other risk factors, including but not limited to, antibiotic use, sexual intercourse, pregnancy, oral contraceptives, and/or diabetes.
• Typical symptoms include thick white vaginal discharge, often accompanied by vulvar pruritus and irritation, external dysuria, and/or dyspareunia.
• C. albicans accounts for 85%-95% of vaginal yeast strains.
• Recurrent vulvovaginal candidiasis is defined as ≥ 3-4 documented, symptomatic, separate episodes within 1 year. The reported prevalence of recurrent vulvovaginal candidiasis in patients with vulvovaginal candidiasis is 9%.

Evaluation

• Suspect vulvovaginal candidiasis in women with thick white "cottage cheese-like" vaginal discharge, often accompanied by vulvar pruritus and irritation, external dysuria, or dyspareunia.
• In a symptomatic woman, confirm the diagnosis with either (Strong recommendation):
  • wet preparation (saline or 10% potassium hydroxide) or Gram stain of vaginal discharge showing yeasts, hyphae, or pseudohyphae
  • culture or other test, such as, polymerase chain reaction or DNA probe test, yielding positive results for a yeast species
• Candidiasis as the cause needs to be distinguished from other common causes of vaginitis, such as, bacterial vaginosis or trichomoniasis. Mixed vaginal infections can also occur.

Management

• Do not treat if the patient is asymptomatic.
• For uncomplicated vulvovaginal candidiasis, effective options include numerous topical agents (usually of the azole class) daily, typically for 3-7 days, or fluconazole (Diflucan) 150 mg orally as a single dose (Strong recommendation). The creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms.
• For complicated vulvovaginal candidiasis (severe disease, infection not caused by C. albicans, or infection in abnormal host) treat with a topical agent for 7-14 days, or with fluconazole 150 mg orally every 72 hours (every 3 days) for 3 doses (Strong recommendation). No data exist supporting the treatment of sex partners of patients with complicated vulvovaginal candidiasis.
• For recurrent vulvovaginal candidiasis treat initially with a topical or oral azole for 10-14 days followed by suppressive therapy using fluconazole 150 mg orally in a single dose weekly for 6 months (Strong recommendation).
• Recent FDA approvals (approved after guideline release) include:
  • ibrexafungerp (Brexafemme) for treatment of VVC and for reduction of recurrent VVC in adults and postmenarchal pediatric female patients.
  • oteseconazole (Vivjoa) for reduction of recurrent VVC in patients with history of recurrent VVC who are not of reproductive potential.
• Culture and susceptibility testing using clinical breakpoints established by the Clinical and Laboratory Standards Institute (CLSI) should be considered when a patient remains clinically symptomatic after treatment or when non-C. albicans isolates are identified because non-C. albicans species are typically resistant to most azole agents. Treatment options for patients with non-C. albicans Candida infection include topical boric acid or nystatin suppositories.
• In pregnancy:
  • The FDA advises caution in prescribing oral fluconazole during pregnancy.
  • Topically applied azole drugs for 7 days are recommended for use in pregnant women with symptomatic vulvovaginal candidiasis.