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Cited by 120Antifungal resistance and susceptibilityReproductive tract infections researchYeasts and Rust Fungi Studies

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Guideline: Vulvovaginal Candidosis (AWMF 015/072), S2k (excluding chronic mucocutaneous candidosis)

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Mendling, Werner·2015·Mycoses
DOI 10.1111/myc.12292
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Abstract

The oestrogenised vagina is colonised by Candida species in at least 20% of women; in late pregnancy and in immunosuppressed patients, this increases to at least 30%. In most cases, Candida albicans is involved. Host factors, particularly local defence mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and oestrogens influence the risk of candidal vulvovaginitis. Non-albicans species, particularly Candida glabrata, and in rare cases also Saccharomyces cerevisiae, cause less than 10% of all cases of vulvovaginitis with some regional variation; these are generally associated with milder signs and symptoms than normally seen with a C. albicans-associated vaginitis. Typical symptoms include premenstrual itching, burning, redness and odourless discharge. Although itching and redness of the introitus and vagina are typical symptoms, only 35-40% of women reporting genital itching in fact suffer from vulvovaginal candidosis. Medical history, clinical examination and microscopic examination of vaginal content using 400× optical magnification, or preferably phase contrast microscopy, are essential for diagnosis. In clinically and microscopically unclear cases and in chronically recurring cases, a fungal culture for pathogen determination should be performed. In the event of non-C. albicans species, the minimum inhibitory concentration (MIC) should also be determined. Chronic mucocutaneous candidosis, a rarer disorder which can occur in both sexes, has other causes and requires different diagnostic and treatment measures. Treatment with all antimycotic agents on the market (polyenes such as nystatin; imidazoles such as clotrimazole; and many others including ciclopirox olamine) is easy to administer in acute cases and is successful in more than 80% of cases. All vaginal preparations of polyenes, imidazoles and ciclopirox olamine and oral triazoles (fluconazole, itraconazole) are equally effective (Table ); however, oral triazoles should not be administered during pregnancy according to the manufacturers. C. glabrata is not sufficiently sensitive to the usual dosages of antimycotic agents approved for gynaecological use. In other countries, vaginal suppositories of boric acid (600 mg, 1-2 times daily for 14 days) or flucytosine are recommended. Boric acid treatment is not allowed in Germany and flucytosine is not available. Eight hundred-milligram oral fluconazole per day for 2-3 weeks is therefore recommended in Germany. Due to the clinical persistence of C. glabrata despite treatment with high-dose fluconazole, oral posaconazole and, more recently, echinocandins such as micafungin are under discussion; echinocandins are very expensive, are not approved for this indication and are not supported by clinical evidence of their efficacy. In cases of vulvovaginal candidosis, resistance to C. albicans does not play a significant role in the use of polyenes or azoles. Candida krusei is resistant to the triazoles, fluconazole and itraconazole. For this reason, local imidazole, ciclopirox olamine or nystatin should be used. There are no studies to support this recommendation, however. Side effects, toxicity, embryotoxicity and allergies are not clinically significant. Vaginal treatment with clotrimazole in the first trimester of a pregnancy reduces the rate of premature births. Although it is not necessary to treat a vaginal colonisation of Candida in healthy women, vaginal administration of antimycotics is often recommended in the third trimester of pregnancy in Germany to reduce the rate of oral thrush and napkin dermatitis in healthy full-term newborns. Chronic recurrent vulvovaginal candidosis continues to be treated in intervals using suppressive therapy as long as immunological treatments are not available. The relapse rate associated with weekly or monthly oral fluconazole treatment over 6 months is approximately 50% after the conclusion of suppressive therapy according to current studies. Good results have been achieved with a fluconazole regimen using an initial 200 mg fluconazole per day on 3 days in the first week and a dosage-reduced maintenance therapy with 200 mg once a month for 1 year when the patient is free of symptoms and fungal infection (Table ). Future studies should include Candida autovaccination, antibodies to Candida virulence factors and other immunological experiments. Probiotics with appropriate lactobacillus strains should also be examined in future studies on the basis of encouraging initial results. Because of the high rate of false indications, OTC treatment (self-treatment by the patient) should be discouraged.

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Research works printed but not linked: 11

  1. Davidson F, 1978, Recurrent vaginal candidosis in women and the effect of intermittent prophylactic treatment, BJ Vener Dis, 54, 176
  2. 10.1128/CMR.13.1.122 · DOI
  3. Koldowsky H, 1999, Candida‐Infektionen des weiblichen Genitaltraktes, 25
  4. Mendling W, 2008, Antimykotische Therapie der vaginalen Hefepilz‐Kolonisation von Schwangeren zur Verhütung von Kandidamykosen beim Neugeborenen, AMWF
  5. Müller J, 1981, Gyno – Travogen, Monographie Excerpta Medica, 81
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  8. 10.3389/fmicrobiol.2012.00294 · DOI
  9. Wilson C, 2005, Recurrent vulvovaginal candidiasis; an overview of traditional and alternative therapies, Adv Nurse Pract., 13, 24
  10. Witkin SS, 2000, New insights into the immune pathogenesis of recurrent vulvovaginal candidiasis, Int J Gynecol Obestet, 3, 114
  11. Young GL, 2001, Topical treatment for vaginal candidiasis (thrush in pregnancy) (review), The Cochrane Database of systematic Reviews, 4, CD 000225

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Metadata

Authors
Mendling, W.
Affiliations
Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe Vogelsangstrasse 106 42109 Wuppertal Germany
Corresponding author
Mendling, Werner
ORCID
Mendling, Werner
Venue
Mycoses
Publisher
Wiley
Published
2015-02-24
Volume
58
Issue
S1
Pages
1-15
ISSN
  • 0027-5557 (ISSN-L)
  • 0933-7407
  • 1439-0507
DOI
10.1111/myc.12292
OpenAlex
W2164957395
Cited by
117
References
161
Citations by year
2026: 1 · 2025: 6 · 2024: 7 · 2023: 6 · 2022: 12 · 2021: 19 · 2020: 17 · 2019: 8 · 2018: 11 · 2017: 11 · 2016: 12 · 2015: 7
FWCI
10.64
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Mycoses (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Life Sciences › Immunology and Microbiology › Microbiology › Reproductive tract infections research
  • Life Sciences › Immunology and Microbiology › Microbiology › Yeasts and Rust Fungi Studies
Keywords
candidal vaginitis, Candida albicans, Candida glabrata, non-albicans Candida, fungal culture, polyenes, imidazole, ciclopirox olamine, 5-fluorocytosine
MeSH terms
Antifungal Agents, Candida albicans, Candidiasis, Vulvovaginal, Female, Germany, Humans, Infant, Newborn, Microbial Sensitivity Tests, Microscopy, Phase-Contrast, Pregnancy, Pregnancy Complications, Infectious, Vaginal Discharge, Candida glabrata

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