An 18-year-old woman presents with severe vaginal and vulvar itching and a thick white discharge. Figure 77-1 shows the appearance of her vulva with redness and excoriations. Note the satellite lesions near the borders of the inflamed areas. Her pelvic examination demonstrated a thick adherent discharge on the vaginal wall and cervix (Figure 77-2) that is consistent with an active candida infection. Treatment with a prescription anti-candida drug was successful.
Vulvovaginal candidiasis (VVC) is a common fungal infection in women of childbearing age. Pruritus is accompanied by a thick, odorless, white vaginal discharge. VVC is not a sexually transmitted disease. On the basis of clinical presentation, microbiology, host factors, and response to therapy, VVC can be classified as either uncomplicated or complicated.1 Uncomplicated VVC is characterized by sporadic or infrequent symptoms, mild-to-moderate symptoms, and the patient is nonimmunocompromised. Complicated VVC is characterized by recurrent (four or more episodes in 1 year) or severe VVC, non-albicans candidiasis, or the patient has uncontrolled diabetes, debilitation, or immunosuppression.1
Candida (Figure 77-3) is usually not isolated in prepubertal girls except when predisposing factors, such as a recent course of antibiotics, diabetes, or the wearing of diapers are present. 2
VVC accounts for approximately 1/3 of vaginitis cases.1
Candida species are part of the lower genital tract flora in 20 to 50 percent of healthy asymptomatic women.3
Seventy-five percent of all women in the US will experience at least one episode of VVC. Of these, 40 to 45 percent will have two or more episodes within their lifetime.4 Approximately 10 to 20 percent of women will have complicated VVC that necessitates diagnostic and therapeutic considerations.
It is a frequent iatrogenic complication of antibiotic treatment, secondary to altered vaginal flora.
Approximately half of all women experience multiple episodes, and up to 5 percent experience recurrent disease.1
Recurrent vulvovaginal candidiasis (RVVC) is defined as four or more episodes of symptomatic VVC in 1 year. It affects a small percentage of women (<5%).5 Recurrent yeast vaginitis is usually caused by relapse, and less often by reinfection. Recurrent infection may be caused by Candida recolonization of the vagina from the rectum.6
Most vulvovaginal Candidiasis is caused by Candida albicans (Figure 77-3).1,7 Candida glabrata now causes a significant percentage of all Candida vulvovaginal infections. This organism is resistant to the nonprescription imidazole creams. It can mutate out of the activity of treatment drugs much faster than albicans species.8
The disease is suggested by pruritus in the vulvar area, together with erythema of the vagina and vulva (Figures 77-1 and 77-2). The familiar reddening of the vulvar tissues is caused by an ethanol by-product of the Candida infection. This ethanol compound also produces pruritic symptoms. A scalloped edge with satellite lesions is characteristic of the erythema on the vulva.
VVC can occur concomitantly with sexually transmitted diseases (STDs).
The pathogenesis of recurrent VVC is poorly understood, and most women with these recurrences have no apparent predisposing or underlying conditions.1
Diabetes mellitus, especially with higher A1C values.
Recent antibiotic use.
Increased estrogen levels.
Immunosuppression.
Contraceptive devices (vaginal sponges, diaphragms, and intrauterine devices).
Genetic susceptibility.
Behavioral factors—VVC may be linked to orogenital and, less commonly, anogenital sex.
Wearing diapers.
Spermicides are not associated with Candida infection.
There is no high-quality evidence showing a link between VVC and hygienic habits or wearing tight or synthetic clothing.
