Diagnosis and treatment of vulvovaginal candidiasis: A practical approach

Candida infections are the second most common cause of vaginal infection, after bacterial vaginosis. The large majority of Candida spp. infections are caused by C. albicans (about 85-95%). The re-maining part is caused by other pathogens such as C. glabrata, C. parapsilosis, C. krusei and C. tropicalis. Episodic vulvovaginal candidiasis (VVC) includes normal women with mild to moderate symptoms and no history of persistent or recurrent symp-toms. Culture-dependent analysis and microscopic examination of vaginal fluid are recommended for episodic VVC diagnosis when the laboratory or clinical facilities are available. The current best test to diagnose Candida in women is microscopy. Complicated VVC may be defined as that which is recurrent (4 or more episodes in 12 months), associated with severe symptoms, the re-sult of a non-albicans species, or present in a compromised host. This condition is more common in those with immunosuppres-sion, diabetes, or both. Additional testing for HIV and diabetes may be warranted in these situations. When there is evidence of complicated VVC, collection of vaginal fluid for culture and yeast speciation may help to identify the therapy because, in such cases, there is an increased likelihood of non-albicans strains. All national and international guidelines include therapeutic options over-the-counter (OTC) or requiring medical prescription. Azoles topical single-use administration represents the therapy of choice of acute vaginal infection by Candida. The treatment with vaginal single dose of clotrimazole or isoconazole or fenticonazole has reported a cure rate of about 95-100% at 7 days and 50-90% at one month. In consideration of the high cure rate and the high tolerability, topical single-dose treatment appear to be considered among the first-choice treatment of vaginal candidiasis. The pres-ence of intense vulvar symptoms may suggest the use of cream alone or together to vaginal capsule according to the intensity of symptoms of complicated VVC. In general, the severity of indi-vidual episodes is based on clinical and not laboratory data. Severe disease may require more intensive treatment. Any woman whose symptoms persist after using an OTC preparation or who has a recurrence of symptoms within 2 months after treatment should be referred to a gynecologist. Unnecessary or inappropri-ate use of OTC preparations is common and can lead to a delay in the treatment of other vulvovaginitis etiologies. Key findings from the literature indicate that lactobacilli treated women after 3 months of follow-up showed a significant increase in vaginal lactobacilli count, a more stable restoration of physiologic pH value and a significant subjective improvement of symptomatic discomforts, such as burning or itching and a modest, but dis-cernable, late effect on vaginal symptoms that could be related to the potential anti-inflammatory/immunomodulatory effects of some strains of lactobacilli. The efficacy of oral or vaginal Lac-tobacillus strains in lowering the risk of VVC recurrence has been shown in observational studies. These results emphasize the importance of defining new therapeutic plans capable of enhancing the effects of conventional antifungal therapy to preserve the eu-biosis of the vaginal microbiota.