• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
GYN
CMECNE

Diagnosis and Treatment of Vulvovaginal Candidiasis

image_pdfFavoriteLoadingFavorite

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the symptoms, exam findings and diagnostic testing of vulvovaginal candidiasis
2. Apply the recommended treatment of uncomplicated and complicated VVC

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Jan 9 2019 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Vulvovaginal candidiasis (VVC) presents with symptoms of itching, redness and discharge. Recurrent VVC (RVVC) is diagnosed when women have ≥4 episodes of VVC within 12 months.

  • Focus on the following when obtaining the history
    • Location | Duration | Relation to menses | Response to prior treatment and self-treatment | Sexual partners | Contraception
    • Note: Self-diagnosis and telephone diagnosis are unreliable
  • Physical exam includes examination of vulva and vaginal vault
    • Signs of inflammation | Ulcers | Excoriation
  • Diagnosis
    • Blastospores or pseudohyphae on saline or 10% KOH microscopy or
    • Positive culture in the presence of symptoms suggestive of candidiasis

Note: Diagnosis based on history and physical alone are unreliable |  If pH paper, KOH, and microscopy are not available, FDA approved commercial tests are available

Classification

Classify as uncomplicated or complicated

  • Uncomplicated
    • Sporadic or infrequent
    • Candida albicans infection (suspected or proven)
    • Non-immunocompromised
    • Mild/ moderate symptoms and findings
  • Complicated
    • Recurrent: ≥4 infections in 12 months
    • Severe symptoms and findings
    • Non-Albicans Candida (NAC)
    • Immunocompromised, including
      • Diabetes | Immunosuppression meds | HIV

SYNOPSIS:

VVC is a common clinical condition with most infections due to C. albicans. Uncomplicated infections respond promptly to 1-,3- and 7- day treatment options (see below).  Complicated/recurrent VVC may require longer duration of treatment and higher doses of medication.  NAC subtypes may be resistant to typical treatment.

KEY POINTS:

  • Candida albicans is the most common cause of VVC
  • NAC
    • Accounts for an increasing number of cases
    • NAC species include
      • glabrata | C. tropicalis | C. krusei | C. parapsilosis | C. guilliermondii
    • Correct identification is important as NACs have resistance/decreased susceptibilities to commonly used treatment

Treatment

Uncomplicated

  • One-day therapy
    • Butoconazole 2% sustained-release cream intravaginally 5 g or
    • Fluconazole 150 mg po (Note – only oral agent) or
    • Miconazole 1,200 mg vaginal suppository or
    • Tioconazole 6.5% ointment 5 gram intravaginally
  • 3-day therapy
    • Clotrimazole 2% cream 5 g daily intravaginally or
    • Miconazole 200 mg vaginal suppository daily or
    • Miconazole 4% cream 5 g intravaginally daily or
    • Terconazole 0.8% cream 5 gm intravaginally daily  or
    • Terconazole 80 mg vaginal suppository daily
  • 7-day therapy
    • Clotrimazole 1% cream 5 g intravaginally daily or
    • Miconazole 2% cream 5 g intravaginally daily or
    • Miconazole 100 mg vaginal suppository
    • Terconazole 0.4% cream 5g intravaginally daily

Complicated 

  • Fluconazole “is an effective and convenient treatment”

Recurrence (Candida albicans)

  • Intensive therapy for 7–14 days
  • Followed by prolonged treatment with fluconazole (first line)
    • Fluconazole 150 mg weekly for 6 months
  • Acceptable alternative prolonged therapy (second line) if patient does not want or cannot tolerate fluconazole
    • Clotrimazole 500 mg weekly or
    • Clotrimazole 200 mg twice a week

Severe Infection (erosions, fissures, edema)

  • Acute infection
    • Topical intravaginal azoles for 10 to 14 days or
    • Oral fluconazole every 3 days (day 1, 4 and 7)

If NAC confirmed

  • Approximately 50% of patients may respond to topical imidazole treatment
  • If unresponsive to topical imidazole treatment use
    • Boric acid 600 mg vaginal capsules daily x 14 days (minimum)
    • Note: Boric acid should not be used during pregnancy or lactation
  • If unresponsive patient, should be referred to a subspecialist

Pregnancy

  • Topical imidazole therapy for “probably” 7 days (CDC)

Note: Oral fluconazole used at high doses for extended periods of time may be associated with a small increase in birth defects | There have been conflicting studies regarding miscarriage and stillbirth | The FDA did not find conclusive evidence for risk of stillbirth or miscarriage with single 150 mg dose (see ‘Related ObG Topics’ below) | The FDA does “advise cautious prescribing of oral fluconazole in pregnancy”

Other treatments

  • Data on the efficacy of the following are currently inconclusive
    • Probiotics | Yogurt | Garlic | Tea tree oil | Low carb diet | Depot medroxyprogesterone | Douching

Learn More – Primary Sources:

ACOG Practice Bulletin 215: Vaginitis in Nonpregnant Patients

An Update on the Roles of Non-albicans Candida Species in Vulvovaginitis

Recurrent Vulvovaginitis

BMJ Clinical Evidence: Candidiasis (vulvovaginal)

CDC STI Treatment Guidelines 2021: Vulvovaginal Candidiasis

BMJ: Recurrent vulvovaginal candidiasis

Take a post-test and get CME credits

TAKE THE POST TEST

Get Guideline Notifications Direct to Your Phone

ObGFirst® – Try It Free! >>

image_pdfFavoriteLoadingFavorite

< Previous
All GYN Posts
Next >

Related ObG Topics:

Practical info for your gynecology practice
Diagnosing Vaginitis – Why the Office Visit Still Matters
Cochrane Review: Oral or Intra-Vaginal Anti-Fungal Treatment for Candidiasis?
Practical info for your gynecology practice
What is ‘Mixed’ Vaginitis? How and When to Treat
Practical info for your gynecology practice
Persistent Vaginitis: Tools and Tips in Diagnosis and Treatment
FDA Reviews Fluconazole in Pregnancy
Bacterial Vaginosis – CDC Diagnosis and Treatment Recommendations
Trichomoniasis: CDC Diagnosis and Treatment Guidelines

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

Are you an
ObG Insider?

Get specially curated clinical summaries delivered to your inbox every week for free

  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Download Your ObG App
HERE!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site