Vulvovaginal candidiasis (VVC) is a common fungal infection characterised by inflammation of the vulval and vaginal epithelium, affecting up to 75% of women at least once in their lifetime.
This webinar was sponsored by Acino and presented by Dr Krishnee Moodley.
The primary causative agent is Candida albicans, responsible for 85-95% of VVC infections, with other species like C. glabrata, C. tropicalis, and C. krusei also implicated.
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Risk factors and clinical presentation
Risk factors for VVC include disruptions in normal vaginal ecology due to broad-spectrum antibiotics, poorly controlled diabetes mellitus, immunosuppression, and hormonal changes. Clinically, VVC can present asymptomatically or with symptoms such as itchiness, vaginal swelling, soreness, dyspareunia, dysuria, and increased discharge. On examination, signs include vaginal discharge, erythema, and abrasions or cracks of the vulva or vagina.
Diagnosis and differential diagnosis
VVC is diagnosed based on clinical features supported by laboratory confirmation of Candida species from a vaginal sample. Differential diagnoses include trichomoniasis and bacterial vaginosis, which present with different discharge characteristics and pH levels.
Classification and management
VVC is classified into uncomplicated and complicated forms. Uncomplicated VVC is typically managed with topical or oral antifungals. Complicated VVC includes severe VVC, recurrent VVC, VVC caused by non-albicans Candida species, and VVC in immunosuppressive conditions.
Recurrent VVC
Recurrent VVC, defined as three or more episodes in less than a year, affects less than 5% of women but has significant economic and psychosocial impacts. Management involves an induction regimen to achieve clinical remission, followed by a maintenance regimen. Recommended induction includes fluconazole 150mg orally every 72 hours for three doses, followed by maintenance with fluconazole 150mg orally once a week for six months.
Non-albicans VVC
Non-albicans VVC, often resistant to fluconazole, may require alternative treatments such as local nystatin or boric acid. However, boric acid is not recommended for women of reproductive age due to its potential embryotoxic effects.
VVC in special populations
In pregnancy, VVC management aims to prevent complications while ensuring safety. Topical azoles are recommended, with fluconazole avoided due to potential associations with congenital malformations. In HIV-infected women,
VVC tends to be more severe and recurrent, but conventional therapy remains effective. Diabetic women are at increased risk due to hyperglycaemia, which promotes fungal adhesion and impairs immune response.
Follow-up and patient education
Routine follow-up is unnecessary for acute uncomplicated VVC, but recurrent VVC requires monitoring and culture testing if symptoms persist. Educating and reassuring patients, along with addressing exacerbating factors, are crucial components of management.
