Vulvovaginal Candidiasis
Tips for Diagnosis and Treatment · ISSVD
Candidiasis
Information
Vulvovaginal Candida Infections
• 13 million cases of vulvovaginal candida (VVC) infections occur annually in the United States.
• Candida albicans is the species which most often causes these infections.
• The second most common species to affect the vulvovaginal area is Candida glabrata.
• Rarely is vulvar candidiasis seen without concomitant vaginal candidiasis.
• Candida is a dimorphic fungus that forms both spores and mycelia.
Symptoms / Signs
Symptoms:
Itching
Burning / Irritation
Pain with urination
Dyspareunia
Vaginal soreness
Signs:
Edema
Fissures
Erythema
Excoriations
Vaginal discharge
The incidence of asymptomatic fungal carriage in the vagina is quoted as 8–15 percent. The asymptomatic patient usually does not require treatment.
Diagnosis
• pH of the vagina from the lateral side wall will generally be less than 4.5 (at times when associated with other conditions it can be > 4.5).
• Evaluation of the wet prep (cotton swab placed in a small amount of normal saline) will reveal hyphal elements or spores.
• Examination of a wet mount with KOH preparation should be performed for all women with symptoms or signs of VVC.
• For patients with negative wet mounts but existing signs or symptoms, vaginal cultures for Candida should be considered.
pH Indicator Strip Example
Diagnosis
Sporadic, infrequent episodes include all of the following:
• < 3 episodes per year
• Mild to moderate signs and symptoms
• Likely infection with Candida albicans
• Healthy woman who is not pregnant
Treatment
Topical creams are often used, but at times they can be irritating. Use as directed by package labeling. All pharmacies may not carry all products. The creams and suppositories are often oil-based and might weaken latex condoms and diaphragms.
Follow Up
• Only necessary if symptoms persist or recur after treatment of onset of initial symptoms.
• If your patient fails to improve, consider obtaining a Candida culture and if positive, test with an antifungal for that species (see Recurrent Infections).
• While sensitivity testing can be obtained, it is not associated with clinical outcomes, so should be deferred in most cases.
Diagnosis
Recurrent (Complicated)
Recurrent Candida infections are defined by ≥ 3 episodes/year of culture verified vulvovaginal candidiasis.
Cultures
• Cultures for yeast should be obtained when symptoms are not explained on the wet prep or a patient presents with recurrent candidiasis.
• Cultures for yeast should be obtained when symptoms are not explained on the wet prep or a patient presents with recurrent candidiasis.
Include one or more of the following:
• ≥ 3 episodes per year of culture-verified vulvovaginal candidiasis
• Severe signs and symptoms
• Often consisting of Candida species other than Candida albicans such as Candida glabrata.
• Candida glabrata and other nonalbicans Candida species are observed in 10%–20% of women with recurrent vulvovaginal candidiasis.
• Poorly controlled diabetes, immunosuppression, pregnancy, or debilitation
• ≥ 3 episodes per year of culture-verified vulvovaginal candidiasis
• Severe signs and symptoms
• Often consisting of Candida species other than Candida albicans such as Candida glabrata.
• Candida glabrata and other nonalbicans Candida species are observed in 10%–20% of women with recurrent vulvovaginal candidiasis.
• Poorly controlled diabetes, immunosuppression, pregnancy, or debilitation
Recurrent Candida
• Culture to identify the species of Candida is recommended.
• Sensitivity testing is rarely needed, unless the patient fails therapies.
Predisposing Factors
• Uncontrolled diabetes mellitus.
• Steroid use (including topical estrogens).
• Antibiotic use.
• Increased frequency of coitus.
• "Candy binges".
• Immune system alterations such as HIV/AIDS may be associated with a higher incidence and greater persistence of yeast infections.
• For patients with new onset recurrent Candida infections that are menopausal, consider glucose testing to rule out diabetes if no other causes are identified.
• Steroid use (including topical estrogens).
• Antibiotic use.
• Increased frequency of coitus.
• "Candy binges".
• Immune system alterations such as HIV/AIDS may be associated with a higher incidence and greater persistence of yeast infections.
• For patients with new onset recurrent Candida infections that are menopausal, consider glucose testing to rule out diabetes if no other causes are identified.
Treatment
Topical creams are often used, but at times they can be irritating. Vaginal tablets or suppositories may be less irritating. One day products may be more irritating than longer use products. Use as directed by package labeling. All pharmacies may not carry all products. The creams and suppositories are often oil-based and might weaken latex condoms and diaphragms.
Women with underlying immunodeficiency, such as those with poorly controlled diabetes or other immunocompromising conditions (e.g., HIV), and those receiving immunosuppression therapy (e.g., corticosteroid treatment) do not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7–14 days) conventional treatment is necessary.
Follow Up
• Only necessary if symptoms persist or recur after treatment of onset of initial symptoms.
• If your patient fails to improve, consider obtaining another Candida culture and if positive for the same species as before, test for susceptibility to antifungals commonly used in vulvovaginal Candida treatment.
• While sensitivity testing can be obtained, it is not associated with clinical outcomes, so should be deferred in most cases.
• For patients that follow up and are not responding to the treatments above, consider the use of topical gentian violet. Concentrations greater than 1% gentian violet should not be used (cause vulvar irritation). Apply 2 to 3 times a day to the vulva for 3 days. For intravaginal treatment, apply 0.5 ml of 1% solution (5 mg) to a tampon. Place in vagina for 3 to 4 hours daily to twice daily for up to 12 days. Gentian violet is a messy treatment regimen. Apply using disposable gloves. Staining of underwear is common.
Yeast Culture / Speciation Results
There are limited data on some of the treatment regimens. The compounded medications generally are suggestions to consider when other agents are not working. The compounded medications are generally used for resistant strains of Candida.
Notes
Additional information can be obtained on pregnancy and vulvovaginal candidiasis infections in the CDC guidelines.
⚠️ Do not use in pregnancy: Flucytosine, Boric acid, Amphotericin B, Fluconazole, or Itraconazole. Instead use maintenance creams for recurrent yeast.
Vulvovaginal candidiasis occurs frequently during pregnancy. Only topical azole therapies, applied for seven days, are recommended for use among pregnant women.
Candida albicans
Nonalbicans Candida
Thick white vulvovaginal discharge from Candida Albicans
Erythema secondary to Candida glabrata
Erythema from candida infection of skin overlying sacrum
Fissures, Erosions, and Pustules from vulvar Candida infection
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Patient Handout
Download or print the patient education handout for your patients.
Michael S. M. Lanham, MD
Hope K. Haefner, MD
Paul Nyirjesy, MD
Jack D. Sobel, MD
Lynette J. Margesson, MD
Libby Edwards, MD
Duane W. Newton, PhD
Colleen K. Stockdale, MD, MS
Claire Danby, MD
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In addition, the guidance is based on information available at the time and may not be updated with the most current information available at subsequent times. The ISSVD is not liable for any deficiencies in the information contained in this app or for any inaccuracies or recommendations made by independent third parties from whom any of the information contained in the app was obtained.
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