Summary

Vulvovaginal Candidiasis (VVC) is an inflammatory condition of the lower genital tract caused by fungal infection, predominantly Candida species. It is an extremely common source of morbidity, affecting 75% of women of reproductive age at least once in their lifetime. Recurrent VVC (RVVC) affects 5-8% of women and can be psychologically devastating.

Unlike Chlamydia or Gonorrhea, VVC is NOT classified as a Sexually Transmitted Infection (STI). It is an Endogenous Infection caused by the overgrowth of commensal flora. However, sexual activity can be a trigger (micro-trauma).

The Classification (Sobel Classification)

We divide VVC into two clinical entities because the management is completely different:

1. Uncomplicated VVC:
   • Sporadic/Infrequent (<3 episodes/year).
   • Mild-Moderate symptoms.
   • Susceptible organism (C. albicans).
   • Healthy, non-pregnant host.
2. Complicated VVC:
   • Recurrent (4+ episodes/year).
   • Severe (Extensive erythema/fissuring).
   • Non-albicans (C. glabrata, C. krusei).
   • Compromised host (Diabetes, HIV, Pregnancy).

Key Facts Table

Examination

• Vulval Inspection: Look for fissures/erythema.
• Speculum: Essential to visualise the vaginal walls and cervix. (Don't just swab the outside!).

Bedside Tests

1. pH Testing (The Most Useful Tool):
   • Place pH paper on the vaginal wall (lateral fornix).
   • pH < 4.5 (Acidic): Consistent with Candida (or normal).
   • pH > 4.5 (Basic): Bacterial Vaginosis or Trichomonas.
   • Rule: If itch + pH >5, it is NOT uncomplicated thrush. Look for mixed infection.
2. Wet Mount Microscopy:
   • Saline slide: Shows budding yeast.
   • 10% Low (Potassium Hydroxide): Lyses epithelial cells, making Hyphae visible.
   • Sensitivity: 50-70% (Microscopy misses 30% of cases!).

Laboratory Tests

1. High Vaginal Swab (HVS) for Culture:
   • Indication: Complicated VVC, Recurrent VVC, Treatment failure.
   • Goal: Identify species (glabrata vs albicans) and sensitivity.
   • Note: PCR swabs are becoming available but Culture remains gold standard for sensitivity testing.
2. HbA1c: Mandatory in any woman with Recurrent VVC.
3. HIV Test: In severe/recalcitrant cases.

Uncomplicated VVC

"Treat the patient, not the swab." Only treat asymptomatic carriage if pregnancy is a factor? No, asymptomatic carriage needs NO treatment.

Options (Equally Effective):

1. Oral: Fluconazole 150mg Single Dose.
   • Pros: Convenient, less mess.
   • Cons: GI upset, drug interactions, takes 24h to work.
2. Topical: Clotrimazole (Canesten).
   • Pessary: 500mg Single Dose.
   • Cream: 10% Single Dose or 2% for 3 nights.
   • Pros: Instant soothing action, safe in pregnancy.
   • Cons: Messy, can weaken condoms.

Severe VVC (Extensive inflammation/Fissures)

Single dose is insufficient.

• Regimen: Fluconazole 150mg Day 1 and Day 4. (Two doses).
• Adjunct: Topical Hydrocortisone/Clotrimazole combo (Canesten HC) to reduce vulval swelling/itch quickly.

Pregnancy

• Contraindication: Oral Fluconazole is associated with miscarriage and congenital heart defects (Tetralogy of Fallot) in high doses. Avoid in 1st trimester.
• Treatment: Topical Clotrimazole.
• Duration: 7 nights usually required (recurrence is high due to hormones).

Recurrent VVC (RVVC)

Definition: 4+ episodes / year. The "Sobel Regimen" (Induction & Maintenance) is the global standard.

Phase 1: Induction (Getting control)

• Fluconazole 150mg every 72 hours for 3 doses (Day 1, 4, 7).
• Goal: Mycological cure (Negative culture).

Phase 2: Maintenance (Suppression)

• Fluconazole 150mg Once Weekly for 6 months.
• Evidence: Reduces recurrence rate from 50% to <10% while on treatment.
• Relapse: Occurs in 40-50% os women after stopping the 6-month course. Can extend to 1 year if needed.
• Liver Safety: Check LFTs if continuing beyond 6 months (rarely hepatotoxic).

Candida Glabrata (Azole Resistant)

Fluconazole will fail.

• First Line: Nystatin Pessaries 100,000 units daily for 14 days. (Polyene antifungal).
• Second Line: Boric Acid Suppositories 600mg daily for 14-21 days.
  • Mechanism: Unknown, but highly effective against non-albicans species.
  • WARNING: Boric Acid is FATAL IF SWALLOWED. Must be labelled "For Vaginal Use Only". Keep away from children. Never use in pregnancy.
• Third Line: Flucytosine cream (Specialist formulation).

Does diet help?

• Sugar: Cutting refined sugar helps in theory (yeast loves glucose), and is crucial for Diabetics. Evidence in euglycaemic women is weak but anecdotal success is high.
• Probiotics:
  • Oral Lactobacillus: Mixed evidence.
  • Vaginal Lactobacillus (Pessaries): Can help restore flora after antibiotics.
  • Verdict: No harm, possible benefit.
• Hygiene:
  • Avoid soaps/shower gels (alkaline pH allows yeast to thrive).
  • Use Emollients (E45/Aqueous cream) as soap substitute.
  • Cotton underwear (breathable).
  • Avoid tight jeans/leggings.
• Partners: Do NOT treat male partners unless symptomatic (Balanitis - itchy penis). Sexual transmission is not the main driver.

BASHH 2019 Guidelines

• Recommend HVS for all recurrent cases.
• Advocate Sobel Regimen for RVVC.
• Highlight Boric Acid for Glabrata.

CDC 2021 Guidelines

• Emphasize typing of Candida species.
• Warn against self-diagnosis (women are wrong 50% of the time - often it's BV).

Key Papers

• Sobel JD et al (NEJM 2004): The landmark RCT proving weekly fluconazole works for maintenance. n=387. Recurrence 6.7% vs 50% in placebo.

• Azole: Class of antifungals (Fluconazole, Clotrimazole) inhibiting ergosterol synthesis.
• Blastospore: The yeast form of Candida (non-invasive).
• Commensal: An organism living harmlessly on the host.
• Dyspareunia: Painful sex.
• Hyphae: The branching, invasive form of Candida.
• Pessary: A tablet inserted into the vagina.
• SGLT-2: Diabetes drug class (Gliflozins) that causes glycosuria. Massive thrush risk.

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