Our expert is Hope K. Haefner, M.D., Professor, Department of Obstetrics and Gynecology at the University of Michigan Health System in Ann Arbor, Michigan.
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A LARGE NUMBER OF WOMEN WILL EXPERIENCE A CANDIDA INFECTION IN THEIR LIVES
In the United States, 75% of women will have a vulvovaginal Candida infection during their lifetimes. In any one year, this means 13 million women will have the vaginal itching, burning, swelling, painful urination, and painful intercourse associated with yeast infections. Candida albicans is the species most often causing these infections. Candida is not considered a sexually transmitted disease, although I’ve had success treating my patient as well as her partner.
CANDIDA INFECTIONS ARE DIVIDED BETWEEN “SIMPLE” AND “RECURRENT”
In 95% percent of Candida cases, the infection will occur less than four times in a year, and we categorize these as cases as simple Candida infections. They are easily treated and their symptoms are generally mild or moderate. However, 5% of women will develop recurrent Candida. They’ll experience four or more infections in the course of a year. Their symptoms can be very uncomfortable and the treatment is more difficult than that of the simple Candida infection. In the near future, the definition of “simple Candida infections” and “recurrent Candida infections” may be changing. Simple infections may be defined as less than three yeast infections in the course of year and “recurrent” will be three or more infections during a year.
TREATING SIMPLE CANDIDA INFECTIONS IS STRAIGHTFORWARD
In the case of a healthy woman who is not pregnant, a single oral dose of 150 mg of fluconazole is often used. Topical creams can be used according to the instructions on the packaging labeling. Vaginal tablets or suppositories may be less irritating than topical creams and longer-use products may be less irritating than one-day products. Recently, a warning regarding the use of fluconazole in pregnancy has been issued by the US Food and Drug Administration (FDA). At this time, only topical antifungals should be used during pregnancy.
TREATING RECURRENT CANDIDA INFECTIONS IS MORE COMPLICATED
Recurrent infections may come from a non-albicans species. In roughly 10% -20% of women with recurrent vulvovaginal candidiasis, Candida glabrata and other non-albicans species are responsible. After culturing to identify the species involved, it is helpful to look up which species are sensitive to which antifungals. If the species is sensitive to fluconazole, and there are no contraindications to that medication in the patient being treated, a prescription for 150 mg by mouth every 3 days for 3 times, followed by 150 mg fluconazole weekly for up to 6 months may be used. Sensitivity testing is generally not needed because we know which species are sensitive to which antifungal medications. On occasion, sensitivities are indicated. We’re seeing some antifungal resistance and effective treatment may require compounded medications.
THE ISSVD iPHONE APP CAN HELP
The International Society for the Study of Vulvovaginal Disease (ISSVD) created an iPhone/iPad App that can help with diagnosis and treatment of Candida infections. In the past, we haven’t been treating Candida as effectively due to lack of information. This app is designed to make the newest treatment information easily accessible and available. It includes medications and dosage recommendations for 10 different types of Candida. It also gives directions for compounded medications, and it has a patient information sheet that you can click on and send to your patients. An important feature of the yeast app is photographs that help with diagnosis. The app is designed not only for the United States, but we hope is it will be a benefit in Third World countries, too. To find the app, on your iPhone or iPad, go to the App Store and type in ISSVD. The app costs $4.99.
DESQUAMATIVE INFLAMMATORY VAGINITIS MIMICS A CANDIDA INFECTION
Occasionally you’ll find a patient who complains of vaginal discharge who thinks that she may have a Candida infection, but on wet prep and culture, there’s no Candida present. Her problem may be desquamative inflammatory vaginitis (DIV), a chronic purulent vaginitis with dyspareunia and irritation on the vestibule/vagina. It’s mainly an inflammatory condition as opposed to a Candida infection, and it’s a diagnosis of exclusion, when other causes of purulent vaginitis have been excluded. The vaginal pH is elevated and there are inflammatory cells and parabasal cells on wet prep. Although we don’t know the etiology and pathogenesis, we do know that anti-inflammatory medications help. The recommended treatment is either local vaginal clindamycin, vaginal corticosteroids, or these two agents combined. As this may be a chronic immune condition, consider maintenance treatment since relapses are common.