Clinical Guide > Comorbidities and Complications > Candidiasis, Vulvovaginal

# Candidiasis, Vulvovaginal

January 2011

### Chapter Contents

      - Background 
      - S: SubjectiveO: ObjectiveA: AssessmentP: PlanPatient Education
ReferencesPotential ARV Interactions
Background 
Vulvovaginal candidiasis is a yeast infection caused by several types of *Candida*, typically *Candida albicans*. This disease is common in all women, but may occur more frequently and more severely in immunocompromised women.

Although refractory vaginal *Candida* infections by themselves should not be considered indicators of HIV infection, they may be the first clinical manifestation of HIV infection and can occur early in the course of disease (at CD4 counts of >500 cells/µL). The frequency of vaginal candidiasis tends to increase as CD4 counts decrease; however, this may be attributable in part to increased use of antibiotics among women with advanced HIV infection.

Risk factors for candidiasis include diabetes mellitus and the use of oral contraceptives, corticosteroids, or antibiotics.
S: Subjective
The patient may complain of itching, burning, or swelling of the labia and vulva; a thick white or yellowish vaginal discharge; painful intercourse; and pain and burning on urination.

The most important elements in the history include the following:
- Type and duration of symptoms
- Previous vaginal yeast infection
- Oral contraceptive use
- Recent or ongoing broad-spectrum antibiotic therapy
- Recent corticosteroid therapy
- Sexual exposures (to evaluate for sexually transmitted infections)
- Diabetes history
- Cushing syndrome
- Obesity
- Hypothyroidism
- Pregnancy
- Use of douches, vaginal deodorants, or bath additives
O: Objective
Perform a focused physical examination of the external genitalia, vagina, and cervix. This may reveal inflammation of the vulva with evidence of discharge on the labial folds and vaginal opening. Speculum examination usually reveals a thick, white discharge with plaques adhering to the vaginal walls and cervix. Bimanual examination should not elicit pain or tenderness and otherwise should be normal.
A: Assessment
Rule out other causes of vaginal discharge and pruritus:
- Bacterial vaginosis
- Atrophic vaginitis
- Chemical or mechanical causes
- Trichomoniasis
- Gonorrhea, chlamydia, and other sexually transmitted infections
- Scabies
- Pediculosis
P: PlanDiagnostic Evaluation
A presumptive diagnosis is made on the basis of the clinical presentation and potassium hydroxide (KOH) preparation:
- Perform microscopic examination of a KOH preparation of vaginal secretions. This usually reveals pseudohyphae and  Candida  spores (presumptive diagnosis).
- Definitive diagnosis rarely is needed, but may be made by analysis of a culture of vaginal secretions; this may be useful if azole-resistant or non- albicans  species are suspected.
- In the presence of urinary tract symptoms (beyond external vulvar burning), perform urinalysis, culture, or both on a clean-catch urine specimen.
- Consider testing for gonorrhea and chlamydia in patients with a history of possible sexual exposure.
TreatmentUncomplicated infectionsTopical medications- Prescribe topical vaginal antifungal agents in the form of cream or suppositories, including the following: butoconazole, clotrimazole, miconazole, nystatin, terconazole, and tioconazole. Treat for 3-7 days and offer refills depending on the time to the next scheduled clinic visit. The creams also may be used on the vulva for treatment of pruritus.

Note that the mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise the patient to use alternative methods to prevent HIV transmission or conception, or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.
Oral medications- Fluconazole 150 mg PO, single dose (see " Treatment notes ," below)
- Itraconazole 200 mg PO BID for 1 day, or 200 mg PO once daily for 3-7 days (see " Treatment notes ," below)
Complicated infectionsSevere or recurrent candidiasis
Severe or recurrent candidiasis is defined as four or more episodes within 1 year. Consider the following treatments:
- Topical therapy as described above, for 7-14 days
- Fluconazole 150 mg PO every 3 days for 3 doses (see  Treatment notes ," below)

For severe cases that recur repeatedly, secondary prophylaxis can be considered (e.g., fluconazole 150 mg PO weekly, or clotrimazole vaginal suppository 500 mg once weekly).
Non-*albicans* candidiasis- Non-fluconazole azole (posaconazole, voriconazole) for 10-14 days (see " Treatment notes ," below)
- Boric acid 600 mg intravaginal gelatin capsules once daily for 2 weeks for refractory cases
- Consult with a specialist
Treatment notes- Systemic azole drugs are not recommended for use during pregnancy, and women taking azoles should use effective contraception. Topical azoles are recommended for the treatment of pregnant women.
- Resistance to azole medications may develop, especially with prolonged use of oral agents.
- Itraconazole should not be used by pregnant women or women considering pregnancy.
- Avoid ketoconazole: Case reports have associated ketoconazole with a risk of fulminant hepatitis (1 in 12,000 courses of treatment with oral ketoconazole). Experts agree that the risks may outweigh the benefits for women with vulvovaginal candidiasis. Ketoconazole interacts with many other drugs, including some antiretroviral drugs.
Potential ARV Interactions
There may be significant drug-drug interactions between certain systemic antifungals, particularly itraconazole, voriconazole, and posaconazole, and ritonavir-boosted protease inhibitors (PIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), or maraviroc. Some combinations are contraindicated and others require dosage adjustment of the ARV, the antifungal, or both. Check for adverse drug interactions before prescribing. For example, voriconazole use is not recommended for patients taking ritonavir-boosted PIs, and dosage adjustment of both voriconazole and NNRTIs may be required when voriconazole is used concurrently with NNRTIs. See Table 15a-e of the U.S. Department of Health and Human Services *Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents.*, or consult with an expert.
Patient Education- Advise patients to wash external genitals daily with a fresh washcloth or water-soaked cotton balls and to wipe the vulva and perirectal area from front to back after toileting. Women should not use baby wipes on inflamed vulval tissue because they may increase irritation.
- Women should avoid the use of perfumed soaps, bubble baths, feminine hygiene or vaginal deodorant products, and bath powders.
- Advise women not to douche.
- Women should wear cotton underwear and avoid tight, constrictive clothing, particularly pantyhose.
- If patients are prescribed medication for vaginal candidiasis, they should take the medication exactly as prescribed and finish the medicine even during a menstrual period.
- Women who continue to have symptoms can purchase Monistat or Gyne-Lotrimin medication over the counter. Advise patients to start using these as soon as symptoms return and to contact the clinic if symptoms worsen while they are taking these medicines.
- Women taking fluconazole or ketoconazole must avoid pregnancy. Some birth defects have been reported.
- The mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise patients to use alternative methods to prevent HIV transmission or conception or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.
- Sex toys, douche nozzles, diaphragms, cervical caps, and other items can reinfect patients if not properly cleaned and thoroughly dried after use.
- Some studies have suggested that eating yogurt with live cultures (check labels) can reduce the occurrence of vaginal yeast infections.
References- Abularach S, Anderson J.  Gynecologic Problems . In: Anderson JR, ed.   A Guide to the Clinical Care of Women with HIV/AIDS, Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005 . Accessed June 30, 2010.
- Centers for Disease Control and Prevention.   Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America .
- Centers for Disease Control and Prevention.   Sexually Transmitted Diseases Treatment Guidelines, 2010.  2010.MMWR 2010 Dec 17; 59 (No. RR-12):1-110.
- Cohn SE, Clark RA.  Sexually transmitted diseases, HIV, and AIDS in women . In: The Medical Clinics of North America, Vol. 87; 2003:971-995.