- If 4 specific episodes of vulvovaginal candidiasis occur within one year, it is considered to be recurrent
- More than 50% of women above 25 years contract vulvovaginal candidiasis
- Six months continued use of fluconazole, itraconazole, or ketoconazole will effectively treat candida
Candidal vaginitis is an infection of the vagina. C. albicans is the major cause; however, yeast and Candida sp are also responsible for this infection. Women account for 15 – 20%, while expectant mothers account for 20 - 40% of candida vaginitis.
Candida vaginitis infection risk factors include:
- Constrictive nonporous undergarments
- Using a wide range spectrum of corticosteroids or antibiotics
- Use of an intrauterine device (IUD)
Postmenopausal women rarely experience candida vaginitis, apart from those under systemic hormone treatment.
Women with recurrent or persistent vulvovaginal candidiasis mostly share with their practitioner about extreme vaginal discomfort. Other symptoms might include pruritus, dysuria, or dyspareunia and vaginal discharge that is odorless. Most women complain of ineffective treatments.
The initial infection can be diagnosed over the phone, but a visit to the doctor is necessary for recurrent episodes. Self-diagnosis can lead to missing more etiologies or simultaneous infection comprising of more than two organisms, which may need different treatments.
When a doctor carries out a physical examination on a vulvovaginal candidiasis patient, vulvar erythema plus a thick discharge inside the vaginal vault is observed. The discharge is white to yellow in color.
Fungal cultures and potassium hydroxide (KOH) help identify the species causing infection and its effective treatment. When vaginal secretion is examined microscopically in a 10% potassium hydroxide preparation, it can display hyphae. If clinical suspicion rises and potassium hydroxide is negative or if there is recurrence of symptoms after treatment, a fungal culture is to be taken. Wet mounts are to be checked for signs of coordinated existence of bacterial vaginosis and trichomoniasis.
Treating Recurrent Candidal Vaginitis
If 4 specific episodes of vulvovaginal candidiasis occur within one year, it is considered to be recurrent. If 3 episodes that are not associated with antibiotics happen in one year, it might also be considered to be recurrent. More than 50% of women above 25 years contract vulvovaginal candidiasis. Less than 5% of the women get an infection again. Testing of vulvovaginal candidiasis is, however, vital. Women who self-diagnose are likely to skip concurrent infections or other causes.
Identified etiologies of repeated vulvovaginal candidiasis comprise of treatment-resistant candida species apart from Candida albicans, contraceptive use, regular antibiotic therapy, infection of the immune system, hyperglycemia, and sexual intercourse.
When microscopic examination of your vaginal secretions inside potassium hydroxide mixture is negative but clinical suspicion rises, fungal cultures are to be taken. After treating an acute episode, maintenance therapy or successive prophylaxis is vital. Long-term therapy is encouraged, as discontinued prophylaxis causes recurrence in most patients. Oral administration of anti-fungal therapy works very well on patients. On the other hand, oral treatment has greater potential for drug interaction and systemic toxicity.
Persistent infection is distinguished from recurring vulvovaginal candidiasis by the presence of a symptom-free interval.
Causes of Recurrence
Vulvovaginal candidiasis is caused by a pathogen called Candida albicans. Other pathogens include Candida glabrata and Candida tropicalis. Candida species cause yeast vaginitis more than C. albicans. Recurrent infections can be brought about by resistance of the non-C. albicans to anti-fungal treatment.
Although treatment failure can be caused by anti-fungal resistance, other factors can cause recurrence. Noncompliance to a treatment program can cause a persistent infection that can be mistaken for recurrence, i.e. not completing anti-fungal therapy, especially when a difficult topical treatment is prescribed. A recurrence represents an incompetently treated infection. After treatment, 15 - 20% of women having negative cultures get a positive culture in 3 months. If an infection recurs afterward, a different C. albicans strain has caused it.
Antibiotic use minimizes defensive vaginal flora, allowing candida species to take over, making it look like a recurrence of the infection. Elongated antibiotic use increases yeast infection. However, no antibiotic has been reported to trigger a yeast infection.
Diabetes mellitus is thought to be a predisposing element for recurrent vulvovaginal candidiasis. Hyperglycemia enables C. albicans to stick on vaginal epithelial cells. If no other symptoms point to diabetes, women with recurring vulvovaginal candidiasis rarely will have diabetes.
Use of contraceptives, like creams and spermicidal jellies, can promote recurrences by causing changes to vaginal flora and rising the candida organisms' bond. Theory has it that progesterone receptors and estrogen are found in candida cells, which rises fungal proliferation when stimulated.
Deficient cell-mediated immunity in women can cause vulvovaginal candidiasis recurrence. Women with acquired immunodeficiency syndrome can contract systemic candida. Certain studies imply that 40 – 70% of patients having recurring vulvovaginal candidiasis have some certain anergy causing a subnormal T-lymphocyte reply to candida.
Mechanical factors, such as perspiration linked with wearing fitted clothes or underpants that are poorly ventilated, raise moist and local temperatures. Clothes or sexual intercourse can irritate the vulvovaginal region, exposing colonized regions to infection. There is a positive relationship with monthly rate of sexual intercourse and prevalence of vulvovaginal candidiasis recurrence.
Dietary habits sometimes cause vulvovaginal candidiasis recurrence, but there is no supporting evidence, as strict diets have not helped.
A study got identical candida strains of sexual partners, and 48% of the women had recurrent infections. When the male partners were treated with ketoconazole (oral), the recurrence frequency for both treated and untreated partner were the same for the period between 6 and 12 months. Topical anti-fungal therapy is not effective in male partners; hence, no treatment can prevent recurrence in women. Elimination of candida in the gastrointestinal tract to avoid reinfection from the intestinal reservoir that causes vaginal recurrences has been suggested, but there is no link between vulvovaginal candidiasis recurrence and intestinal candida.
Vaginal swabs should be taken before starting treatment. If the first treatment doesn’t work after one week’s use and neither does vaginal anti-fungals, diagnose again.
Women’s personal care
Swollen epithelium is very sensitive to physical trauma and chemicals. Special care and hygiene has to be practiced by using normal saline. Avoid soap, over-the-counter preparations, and home remedies. Use cotton to apply saline, then pat dry using a soft cloth.
C. albicans infection treatment
Vaginal imidazole should be applied at night for candidal vulvovaginitis treatment. Other preparations are also effective on candidiasis.
Recurrent candidiasis treatment
If candidiasis reoccurs after treatment before 6 months are over, vaginal swabs should be taken; a laboratory test confirmation to manage the suspected infection is also vital. However, the treatment recommended is seven days of vaginal imidazole.
Change of the vaginal surroundings
Change contraceptive method to get rid of medroxyprogesterone acetate and lower oestrogen dose for women undergoing hormone replacement treatment.
Long-term vaginal treatment
Insertion of nystatin in tablet, pessary, or vaginal cream form will clear candidiasis, and no discharge will be produced even during the day. Apply during menstruation, too. This treatment should go on for 6 months for severe cases. Expectant mothers with multiple infections should use prophylaxis to the last day before experiencing labor.
Long-term oral treatment
Six months continued use of fluconazole, itraconazole, or ketoconazole will effectively treat candida.
Treat every recurrence thoroughly
For multiple recurrences, use vaginal imidazole. Apply the cream for 14 days, even during menstruation. Incorporate ketoconazole by applying a course two times a day for five days. This regimen is known to minimize the rate of recurrences.
Candidal vaginitis is fairly common. It seems like many women experience recurrences of this infection. It is important to complete any treatment course to full remove the infection and avoid recurrence. A doctor should be contacted for treatment.