Fungal Infections Candidiasis

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Vulvovaginal yeast infections are very common, medically trivial but sometimes symp-tomatically miserable infections. Most women and many physicians rightly or wrongly attribute nearly all vulvovaginal symptoms to vulvovaginal candidiasis.

The majority of vulvovaginal yeast is produced by Candida albicans, but an increasingly large proportion of yeast infections involve Candida glabrata, Candida tropicalis, Candida parapsilosis, Candida krusei, Candida lusitaniae, Saccharomyces cerevisiae, or even less common organisms (44). Because the colon is a natural reservoir for yeast, occluded, moist, warm anogenital skin provides an ideal environment for infection, particularly in the setting of risk factors such as use of antibiotics, vigorous sexual activity, diabetes, incontinence, immunosuppression, and obesity.

The symptoms and clinical abnormalities of vulvovaginal candidiasis are extremely variable. C. albicans and C. tropicalis most often present with introital itching, and the less common widespread vulvar involvement produces more widespread itching. Other yeast forms generally only affect the vagina and vestibule, and produce

Table 14

Bacterial Vaginitis









Introital irritation,

Erythema of the


Topical or



vestibule and




vagina; vaginal



secretions with


evaluation for

increased white



blood cells,


immature cells

symptoms of burning, irritation, rawness, and soreness rather than itching. Women and infants who are estrogen deficient rarely experience vaginal yeast infections, although the anogenital skin can certainly exhibit C. albicans infections.

Most often, the physical examination only shows vestibular erythema. However, more severe infections exhibit more of the following vulvar abnormalities: erythema, edema of the modified mucous membranes, a superficial, shiny "glazed" texture, fissuring of skin folds, peripheral scale and peeling, and satellite red papules, pustules, and collarettes (circular scale that represents the edges of a desquamated blister roof) (Figs. 17 and 18). The vagina may or may not exhibit erythema. Although vaginal secretions are generally reported as a dry "cottage cheese'' consistency, vaginal secretions are often normal clinically.

The differential diagnosis consists of several of the diseases characterized by itching, redness, and fissuring. Most common is lichen simplex chronicus (eczema/ atopic dermatitis), often with intermittent, superimposed Candida infection. Lichen

Vulva Insert

Figure 17 (See color insert) Vulvovaginal candidiasis can produce redness, edema, and fissuring.

Labia Majora Crease

Figure 18 Candidiasis of dry, keratinized skin such as the labia majora and crural creases is manifested as very superficial and fragile pustules that rupture almost immediately, leaving desquamating collarettes.

sclerosus and irritant or allergic contact dermatitis are also common confusing processes. Often, patients with chronic symptoms of vulvodynia are misdiagnosed with vulvovaginal candidiasis, but vulvodynia should produce symptoms of irritation, rawness, or burning rather than itching.

The diagnosis can be suspected by the history and physical examination, but this should be confirmed by microscopic examination or culture. Vaginal secretions of patients with C. albicans or C. tropicalis infection examined on a wet mount or potassium hydroxide preparation shows branching hyphae/pseudohyphae with budding yeast. Lactobacilli are nearly always abundant, resulting in a normally acid vaginal pH. White blood cells can be either increased or normal in number. Otherwise, nonalbicans Candida infection shows only budding yeast, which can be more difficult to visualize microscopically. Therefore, negative microscopic evaluations should be followed up by culture. In addition, recalcitrant yeast infections should be reevaluated by culture as false-positive microscopic examinations because of artifacts are common and patients are sometimes labeled incorrectly as having resistant or recalcitrant yeast infections.

The treatment of vulvovaginal candidiasis is usually very easy. There are multiple therapies available, and all are quite effective for C. albicans and C. tropicalis. Topical and oral azoles all very effectively treat vulvovaginal C. albicans infections. Diflucan 150 mg by mouth is an effective treatment approved by the U.S. Food and Drug Administration (FDA), and trials have shown itraconazole 200 mg a day for three days to be beneficial as well (45). Patients with marked vulvar involvement may require more vigorous treatment, and those with substantial inflammation and fissuring sometimes experience burning with application of these creams. These patients often require several days of an oral azole or the application of soothing nystatin ointment in addition to standard treatments for vaginal candidiasis. Although more is being written about resistant C. albicans in immunocompetent patients, these authors have not observed this phenomenon. All ''resistant'' yeast infections in immunocompetent women have been either nonalbicans Candida infection or a different underlying diagnosis altogether.

Nonalbicans Candida infections are frequently resistant to therapy (46). Generally, a course of any standard anticandidal therapy is prescribed. Those who fail this are usually given either boric acid vaginal capsules 600 mg once or twice a day for two to four weeks or flucytosine cream (47). Nystatin vaginal tablets or ointment twice a day for two to four weeks is a time-honored and soothing treatment that occasionally is useful in nonalbicans Candida infections resistant to azoles. Gentian violet can be beneficial but irritating. Amphotericin intravaginally has been used with some success (48). Very often, the infection does not clear, but symptoms can be controlled with less frequent dosing.

Some patients experienced frequently recurrent vulvovaginal candidiasis. These patients can generally be managed with fluconazole 150 mg weekly (49), although a very rare patient requires every fourth day dosing. Medication is continued for three to six months. In some women, the fluconazole has broken this cycle and can be discontinued. Other patients require a longer course. Hepatotoxicity is not a major concern with weekly dosing, but some clinicians obtain liver function tests several times a year. Some women benefit from oral or topical therapy as a preventive at times of high-risk such as during antibiotic therapy, vigorous sexual activity, or before menses.

Although some clinicians and patients believe that diet, use of oral or vaginal lactobacillus supplements, and special disinfecting of underwear can minimize or treat vulvovaginal candidiasis, there are no data to support these beliefs (50,51). In addition, there is no evidence that vulvovaginal candidiasis produces systemic symptoms of depression, bloating, constipation, headaches, etc (Table 15).

Table 15 Vulvovaginal Candida Albicans

Diagnosis Symptoms Clinical appearance Differential diagnosis


Vulvovagin- Vulvovagi-al Candida nal pru-albicans ritus



Irritation, soreness, burning

Variable from no abnormalities on examination to vulvar erythema, edema, scale, collarettes, vaginal redness. Vaginal secretions sometimes white and clumped, always with fungal elements microscopically

Normal exam, budding yeast microscopically

Vulvar diseasepsoriasis, lichen simplex chronicus/ eczema, tinea cruris; Vaginal disease— bacterial vaginosis, bacterial vaginitis, desquamative inflammatory vaginitis, atrophic vaginitis, vulvodynia/ vestibulitis (vestibulodynia) Vulvodynia/vulvar vestibulitis (vestibulodynia)

Topical—any azole cream q.d.-b.i.d. to the vulva, cream or suppository hours one to seven nights, oral—fluconazole 150 mg PO once

Same as for C. albicans if resistant. Boric acid, nystatin, flucytosine, gentian violet, amphotericin

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