Refresh your memory on “Vulvo vaginal candiadiasis”. This is commonly due to invasion by C albicans but occasionally is caused by other Candida species or yeasts .Please do remember that VVC is not usually acquired through sexual intercourse no data support the treatment of sex partners.
What may be the clinical features ?? Ans: Symptoms include pruritus virginal soreness dyspareunia external dysuria and abnormal vaginal discharge. This is by uncomplicated Vulvo vaginal candiadiasis .But a severe case may present from simple candidal vaginitis to dysuria and vulval pruritus, pain & swelling in vulval areas . Signs over vulva are include vulvar edema, fissures , excoriations or thick curdy vaginal discharge. It is more common in pregnancy period and in the premenstrual period.
Do U have a microscope at your chamber?? Hyphae can be observed by wet smear /Gm stain at your clinic. How to clinically diagnose candida infn?? Ans: The diagnosis can be made when either a wet preparation or Gram stain of vaginal discharge demonstrates Hyphae or pseudohyphae . Culture is possible but limited to metro cities . That will offer the yeast species.
I do have pH paper at my clinic: Will that be helpful??? : Sorry :: No . Candida vaginitis is associated with a normal vaginal pH and therefore pH testing is not a useful diagnostic tool Indentifying candida by culture in the absence of symptoms or signs is not an indication for treatment because approximately 10 to 20 % of women harbor Candida sp and other yeasts in the vagina.
Treatment of candida infections
Azoles is the mainstay. Next in order of merit is Nystatin Short course topical formulations are effective. The topically applied azole drugs are more effective than Nystatin.
Choice is yours:: Topical drugs for fungi (VVC) and doage
A) Clotrimazoles 1% cream 5 gm intra virginally for 7-14 days or B) clotrimazoles 2% cream 5 gm intravaginally for 3 days C) Miconazole 2% cream 5 gm intravaginally for 7 days or D) miconazole 4% cream 5 gm intra vaginally for 3 days or E) Miconazole 100 mg vaginal suppository one suppository for 7days or F) miconazole 200 mg vaginal suppository one suppository for 3 days or G) miconazole 1200 mg vaginal suppository one suppository for 1 day.
What about in pregnancy period ?? Ans:--Miconozole is pregnancy category C and clotrimazoles is a category B oral medication.
Recurrence!!!! Think seriously for office based testing Any woman whose symptoms persists after using an over the counter preparation or who has a recurrent of symptoms within two months “?? How to manage such cases ??? Such cases 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.
Drugs for VVC(Vulvo vaginal candiasis) :: Systemic Antifungal:- : A) 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 B) to oral Itraconazole 200 mg at two doses 12 hours apart.
B) Slightly greater efficacy may be achieved with fulconazole 100 mg / day for 5 to 7 days or intraconazole 200 mg / day for 3 to 5 days.
Complicated Vulvo vaginal Candidiasis: What to do??
This occurs in cases with recurrent VVC severe VVC non albicans candiadiasis and women with diabetes debilitation or immunosuppression. In women with 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.
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 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 ans 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 . A) Either 7 to 14 days of topical azole or B) 150 mg of fulconazole in two sequential doses is recommended. In severe or very symptomatic Candida vulvitis 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.
What may be the clinical features ?? Ans: Symptoms include pruritus virginal soreness dyspareunia external dysuria and abnormal vaginal discharge. This is by uncomplicated Vulvo vaginal candiadiasis .But a severe case may present from simple candidal vaginitis to dysuria and vulval pruritus, pain & swelling in vulval areas . Signs over vulva are include vulvar edema, fissures , excoriations or thick curdy vaginal discharge. It is more common in pregnancy period and in the premenstrual period.
Do U have a microscope at your chamber?? Hyphae can be observed by wet smear /Gm stain at your clinic. How to clinically diagnose candida infn?? Ans: The diagnosis can be made when either a wet preparation or Gram stain of vaginal discharge demonstrates Hyphae or pseudohyphae . Culture is possible but limited to metro cities . That will offer the yeast species.
I do have pH paper at my clinic: Will that be helpful??? : Sorry :: No . Candida vaginitis is associated with a normal vaginal pH and therefore pH testing is not a useful diagnostic tool Indentifying candida by culture in the absence of symptoms or signs is not an indication for treatment because approximately 10 to 20 % of women harbor Candida sp and other yeasts in the vagina.
Treatment of candida infections
Azoles is the mainstay. Next in order of merit is Nystatin Short course topical formulations are effective. The topically applied azole drugs are more effective than Nystatin.
Choice is yours:: Topical drugs for fungi (VVC) and doage
A) Clotrimazoles 1% cream 5 gm intra virginally for 7-14 days or B) clotrimazoles 2% cream 5 gm intravaginally for 3 days C) Miconazole 2% cream 5 gm intravaginally for 7 days or D) miconazole 4% cream 5 gm intra vaginally for 3 days or E) Miconazole 100 mg vaginal suppository one suppository for 7days or F) miconazole 200 mg vaginal suppository one suppository for 3 days or G) miconazole 1200 mg vaginal suppository one suppository for 1 day.
What about in pregnancy period ?? Ans:--Miconozole is pregnancy category C and clotrimazoles is a category B oral medication.
Recurrence!!!! Think seriously for office based testing Any woman whose symptoms persists after using an over the counter preparation or who has a recurrent of symptoms within two months “?? How to manage such cases ??? Such cases 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.
Drugs for VVC(Vulvo vaginal candiasis) :: Systemic Antifungal:- : A) 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 B) to oral Itraconazole 200 mg at two doses 12 hours apart.
B) Slightly greater efficacy may be achieved with fulconazole 100 mg / day for 5 to 7 days or intraconazole 200 mg / day for 3 to 5 days.
Complicated Vulvo vaginal Candidiasis: What to do??
This occurs in cases with recurrent VVC severe VVC non albicans candiadiasis and women with diabetes debilitation or immunosuppression. In women with 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.
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 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 ans 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 . A) Either 7 to 14 days of topical azole or B) 150 mg of fulconazole in two sequential doses is recommended. In severe or very symptomatic Candida vulvitis 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.
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