Vulvo vaginal candidiasis

 What a clinician need to know about :-“ Vaginal  candidiasis” .How to treat Vulvo vaginal candidiasis ??

V V  C( Vulvo vaginal candidiasis) :--Treatment of Fungal diseases :- To remember that Miconazole is pregnancy category C and  clotrimazoles is a category B   oral   medication.

Short course topical formulations at   are effective. The topically    applied azole drugs   are more effective than Nystatin. Such Topical agents are

 1) Clotrimazoles  2%  cream 2)   5% cream 3) Miconazole 100 mg /200 mg vaginal suppository or even 1200 mg Vaginal  pessary   ,,

 1) Clotrimazoles 1%  cream 5 gm intra vaginally  for  7-14  days or

2) Clotrimazoles 2% cream 5 gm intravaginally for 3 days

3) Miconazole 2%   cream 5 gm intravaginally for 7 days or

 4)  Miconazole 4% cream 5 gm intra vaginally    for 3 days or

 5) Miconazole 100 mg vaginal suppository   one suppository for 7days or

6) Miconazole 200 mg vaginal suppository one suppository for 3 days

 7) Miconazole 1200  mg vaginal  suppository one suppository for 1 day.

Office based testing when??  :-Any woman whose symptoms persist after using an over the counter preparation or who has a recurrent of symptoms  within 2   months should be evaluated with office based testing . Unnecessary or inappropriate use for OTC   preparations is common and can lead to a delay in the treatment of other disease. VVC is not usually acquired through sexual   intercourse no data support  the treatment    of sex partners.

 Any Systemic Treatment for VVC?? : A single oral dose of 150 mg of fulconazole has been approved by US Food and Drug Administration for the treatment of vaginal  candiadiasis. Its  efficacy is equivalent  to topical  therapy and  to oral Itraconazole 200 mg     at two doses 12 hours   apart.

Slightly greater  efficacy may be achieved  with fulconazole 100 mg / day for 5 to 7 days or Itraconazole  200 mg / day for 3 to 5 days.

  What are Complicated Vulvo vaginal Candidiasis

Includes 1)  recurrent VVC   severe VVC 2)  non albicans candiadiasis and women with 3)  diabetes debilitation or 4)  immunosuppression.

Recurrent vulvo vaginal candiadiasis

RVVC usually defined as four   or more episodes of symptomatic VVC in 1 year affects a small percentage of women . The pathogenesis   of RVVC is poorly understood and most women with  RVVC have no apparent predisposing or underlying conditions. Vaginal  cultures should be obtained from patients with RVVC  to  confirm   the clinical diagnosis and    to identify unusual species  particularly   candida glabrata ,Although  C glabrata and other non albicans candida  species are  observed  in 10 to 20 % of patients    with RVVC , C glabratea does not form   pseudohyphae or   Hyphae and is not easily recognized on microscopy. Conventional antimycotic therapies are not as effective against these  species as they are against C albians

In cases of recurrent vulvo vaginitis  treatment of the  patient’s   well to short duration oral or topical  azole therapy To maintain clinical and mycologic   control  

a longer duration of initial therapy   or a 100 ,150 or 200 mg oral dose of fulconazole every third day for a total of three doses   should be attempted to obtain mycologic remission before   initiation of a maintenance  antigungal regimen .

Maintenance  regimens.

Oral   fulconazole weekly for 6 months  is the first line of treatment  

. If this regimen is  not  feasible topical  treatments used  intermittently as a maintenance regimen   can  be  considered.

Suppressive maintenance   antifungal   therapies  are effective in  reducing  RVVC  However  30 to 50%  of women will have recurrent  disease after maintenance therapy   is discontinued. Routine    treatment of sexual  partners is controversial.

 C  albicans   azole resistance   is rare in vaginal  isolates and susceptibility testing  is usually  not warranted  for individual treatment  guidance.

Severe  Vulvo vaginal   Candidiasis

Severe  vulvo vaginitis        is associated with  lower clinical  response     rates in patients   treated with short courses of topical  or oral  therapy .

Either  7 to 14 days of topical   azole or 150 mg of fulconazole in two    sequential doses   is recommended.

In severe or very  symptomatic Candida  vulvitus  a topical  corticosteroid for the first 3 to 4 days may be  used .

Non albicans VVC

Options though  not very   clear  include  a 7-14   days therapy  with oral  or systemic  non flucanazole azole   drug   . If  recurrence  occurs 600 mg of boric acid  in a gelatin   capsule   administered  vaginally   once a day  for 2 weeks is recommended. 

In the skin  the most common site   is in the skin folds also  called Candida intertrigo . This   is seen under pendulous breasts between   overhanging  abdominal folds  in the groin

·         Cutaneous Fungal infn( T corporis) 1) Can try terbinafine oint Twice daily for 15 days

·           2) Phytoral cream LA BD

o    · 

·          3) Lulliconazole ointment
For 2weeks

·         · Steriod cream

·          Anti fungal treatment

·          Candidiasis treatment with antifungal

·         Apart from routine treatment of intractable itching like miconazole and steroids like clobetasol also rule out any malignant changes with toludine blue test to look for abnormal areas. It's very rare though but we have to be vigilant

1

·         Break itch scratch cycle. .Oral antihistaminic and I advise pts to rub oil ,petroleum jelly in circular motion when scratchy feeling is too intense ..Clobetasol only for brief duration ,to suppress itch..

·          Some alpazolam at night so her night is not disturbed and she is able to tide over this period.
Also get Liver enzymes tested ..

o     

·          4) Oral Tab terbinafine 250 od for 14 days .

·