Clinical Guide > Comorbidities and Complications > Candidiasis, Vulvovaginal

Candidiasis, Vulvovaginal

January 2011

Chapter Contents

Background

Vulvovaginal candidiasis is a yeast infection caused by several types of Candida, typically Candida albicans. This disease is common in all women, but may occur more frequently and more severely in immunocompromised women.

Although refractory vaginal Candida infections by themselves should not be considered indicators of HIV infection, they may be the first clinical manifestation of HIV infection and can occur early in the course of disease (at CD4 counts of >500 cells/µL). The frequency of vaginal candidiasis tends to increase as CD4 counts decrease; however, this may be attributable in part to increased use of antibiotics among women with advanced HIV infection.

Risk factors for candidiasis include diabetes mellitus and the use of oral contraceptives, corticosteroids, or antibiotics.

S: Subjective

The patient may complain of itching, burning, or swelling of the labia and vulva; a thick white or yellowish vaginal discharge; painful intercourse; and pain and burning on urination.

The most important elements in the history include the following:

O: Objective

Perform a focused physical examination of the external genitalia, vagina, and cervix. This may reveal inflammation of the vulva with evidence of discharge on the labial folds and vaginal opening. Speculum examination usually reveals a thick, white discharge with plaques adhering to the vaginal walls and cervix. Bimanual examination should not elicit pain or tenderness and otherwise should be normal.

A: Assessment

Rule out other causes of vaginal discharge and pruritus:

P: Plan

Diagnostic Evaluation

A presumptive diagnosis is made on the basis of the clinical presentation and potassium hydroxide (KOH) preparation:

Treatment

Uncomplicated infections

Topical medications

Note that the mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise the patient to use alternative methods to prevent HIV transmission or conception, or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.

Oral medications

Complicated infections

Severe or recurrent candidiasis

Severe or recurrent candidiasis is defined as four or more episodes within 1 year. Consider the following treatments:

For severe cases that recur repeatedly, secondary prophylaxis can be considered (e.g., fluconazole 150 mg PO weekly, or clotrimazole vaginal suppository 500 mg once weekly).

Non-albicans candidiasis

Treatment notes

Potential ARV Interactions

There may be significant drug-drug interactions between certain systemic antifungals, particularly itraconazole, voriconazole, and posaconazole, and ritonavir-boosted protease inhibitors (PIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), or maraviroc. Some combinations are contraindicated and others require dosage adjustment of the ARV, the antifungal, or both. Check for adverse drug interactions before prescribing. For example, voriconazole use is not recommended for patients taking ritonavir-boosted PIs, and dosage adjustment of both voriconazole and NNRTIs may be required when voriconazole is used concurrently with NNRTIs. See Table 15a-e of the U.S. Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents., or consult with an expert.

Patient Education

References