Vaginal candidiasis

Vaginal candidiasis (also called vulvovaginal candidiasis) is a common mucosal fungal infection primarily caused by Candida albicans. It results from overgrowth of Candida species in the vagina when the normal vaginal flora and immunity are disrupted.

It is one of the most frequent causes of vaginal discharge in women of reproductive age.

Predisposing Factors

• Pregnancy

• Diabetes mellitus (especially uncontrolled)

• Prolonged antibiotic use

• Corticosteroid therapy

• Immunosuppressive treatment

• HIV/AIDS

• Prolonged use of oral contraceptive pills

• Tight or non-breathable clothing

• Poor genital hygiene

Pathophysiology

Candida normally colonizes the vagina in small numbers.

When:

• Vaginal pH changes

• Lactobacilli decrease

• Immunity is suppressed

Candida transforms from yeast form to invasive hyphal form, leading to:

• Mucosal inflammation

• Epithelial damage

• Thick white discharge

• Intense itching

Clinical Presentation

A. Vaginal Symptoms (Primary Focus)

• Intense vulval itching (pruritus)

• Thick, curd-like whitish vaginal discharge

• Vulval erythema and swelling

• Burning sensation

• Dysuria (pain during urination)

• Dyspareunia (pain during sexual intercourse)

• Vaginal soreness

B. Associated Candida Infections (May Co-exist)

• Intertrigo: erythematous moist rash with satellite pustules

• Oral thrush: white adherent plaques in buccal cavity

• Paronychia: painful swelling around nail folds

• Esophageal candidiasis (in immunocompromised): odynophagia

Diagnostic Criteria

Diagnosis is mainly clinical.

Typical Findings

• Thick curd-like white discharge

• Normal vaginal pH (≤ 4.5)

• Vulval erythema and edema

• Excoriations from scratching

Supporting Laboratory Findings

• KOH wet mount: budding yeast and pseudohyphae

• Gram stain: Gram-positive budding yeast

• Vaginal swab culture (if recurrent or resistant)

Differential Diagnosis

• Bacterial vaginosis

• Trichomoniasis

• Contact dermatitis

• Atrophic vaginitis

• Sexually transmitted infections

Investigation

Treatment

A. Non-Pharmacological Treatment

• Maintain good genital hygiene

• Keep genital area dry

• Avoid tight synthetic underwear

• Use cotton underwear

• Avoid unnecessary antibiotic use

• Control blood glucose in diabetics

• Avoid perfumed soaps/douches

B. Pharmacological Treatment

First-Line (Uncomplicated VVC)

• Nystatin vaginal pessariesInsert one at night for 14 days

OR

• Clotrimazole vaginal pessariesInsert one at night for 6 days

OR

• Miconazole vaginal pessariesInsert one at night for 3 days

If Severe or Recurrent

• Fluconazole (PO) 150 mg stat dose

For severe cases, may repeat after 72 hours.

Recurrent Vaginal Candidiasis (≥4 episodes/year)

• Fluconazole 150 mg weekly for 6 months (maintenance therapy)

Special Considerations

Pregnancy

• Use topical azoles for 7–14 days

• Avoid oral fluconazole in pregnancy unless clearly indicated

HIV Patients

• May require longer treatment duration

• High recurrence rate

Sexual Partners

• Routine partner treatment is not required unless symptomatic

Complications

• Recurrent vulvovaginal candidiasis

• Vulval excoriation and secondary bacterial infection

• Psychosexual distress

• Rare systemic spread in severely immunocompromised patients

Prevention

• Good genital hygiene

• Avoid prolonged antibiotic use

• Tight glycemic control in diabetics

• Avoid douching

• Wear breathable cotton underwear

• Change out of wet clothing promptly

• Proper immune management in HIV patients

Prognosis

• Excellent in immunocompetent women

• High recurrence in diabetics and immunosuppressed

• Proper risk factor control reduces recurrence significantly