Table 18.2 Vulvovaginal Candidiasis—Topical Treatment Regimens 2% cream, 5 g intravaginally for 3 daysa,b 1% cream, 5 g intravaginally for 7–14 daysa,b 2% cream 5 g intravaginally for 3 days 2% cream, 5 g intravaginally for 7 daysa,b 200-mg vaginal suppository for 3 daysa 100-mg vaginal suppository for 7 daysa,b 4% cream 5 g intravaginally for 3 days 1,200 mg vaginal suppository, one suppository for one day 100,000-U vaginal tablet, one tablet for 14 days 6.5% ointment, 5 g intravaginally, single dosea 0.4% cream, 5 g intravaginally for 7 daysa 0.8% cream, 5 g intravaginally for 3 daysa 80-mg suppository for 3 daysa aOil-based, may weaken latex condoms. bAvailable as over-the-counter preparation. Adapted from Centers for Disease Control and Prevention. The sexually transmitted diseases treatment guidelines. MMWR 2006;55:[RR-11]:1–94.
treatment with a weak topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irritative symptoms.
A small number of women develop recurrent VVC (RVVC), defined as four or more episodes in a year. These women experience persistent irritative symptoms of the vestibule and vulva. Burning replaces itching as the prominent symptom in patients with RVVC. The diagnosis should be confirmed by direct microscopy of the vaginal secretions and by fungal culture. Many women with RVVC presume incorrectly they have a chronic yeast infection. Many of these patients have chronic atopic dermatitis or atrophic vulvovaginitis.
The treatment of patients with RVVC consists of inducing a remission of chronic symptoms with ﬂuconazole (150 mg every 3 days for three doses). Patients should be maintained on a suppressive dose of this agent (ﬂuconazole, 150 mg weekly) for 6 months. On this regimen, 90% of women with RVVC will remain in remission. After suppressive therapy, approximately half will remain asymptomatic. Recurrence will occur in the other half and should prompt reinstitution of suppressive therapy (27).
Inﬂammatory Vaginitis Desquamative inﬂammatory vaginitis is a clinical syndrome characterized by diffuse exudative vaginitis, epithelial cell exfoliation, and a profuse purulent vaginal discharge (28). The cause of inﬂammatory vaginitis is unknown, but Gram stain findings reveal a relative absence of normal long gram-positive bacilli (lactobacilli) and their replacement with gram-positive cocci, usually streptococci. Women with this disorder have a purulent vaginal discharge, vulvovaginal burning or irritation, and dyspareunia. A less frequent symptom is vulvar pruritus. Vaginal erythema is present, and there may be an associated vulvar erythema, vulvovaginal ecchymotic spots, and colpitis macularis. The pH of the vaginal secretions is uniformly higher than 4.5 in these patients.
Initial therapy is the use of 2% clindamycin cream, one applicator full (5 g) intravaginally once daily for 7 days. Relapse occurs in about 30% of patients, who should be retreated with intravaginal 2% clindamycin cream for 2 weeks. When relapse occurs in postmenopausal patients, supplementary hormonal therapy should be considered (28).