PUB - Publikationen an der Universität Bielefeld

The estrogenized vagina is colonized by Candida species in at least 20 % of women; in late pregnancy and in immunosuppressed patients this increases to at least 30 %. In most cases Candida albicans is involved. Host factors, particularly local defense mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and estrogens influence the risk of candidal vulvovaginitis. Non-albicans species, particularly Candida glabrata, and in rare cases also Saccharomyces cerevisiae, cause less than 10 % of all cases of vulvovaginitis with some regional variation; these are generally associated with milder signs and symptoms than normally seen with a Candida albicans-associated vaginitis. Typical symptoms include premenstrual itching, burning, redness and odorless discharge. Although itching and redness of the introitus and vagina are typical symptoms, only 35–40 % of women reporting genital itching in fact suffer from vulvovaginal candidosis. Medical history, clinical examination and microscopic examination of vaginal content using 400 × optical magnification, or preferably phase contrast microscopy, are essential for diagnosis. In clinically and microscopically unclear cases and in chronically recurring cases, a fungal culture for pathogen determination should be performed. In the event of non-Candida albicans species the minimum inhibitory concentration (MIC) should also be determined. Chronic mucocutaneous candidosis, a rarer disorder which can occur in both sexes, has other causes and requires different diagnostic and treatment measures. Treatment with all antimycotic agents on the market (polyenes such as nystatin; imidazoles, such as clotrimazole; and many others including ciclopirox olamine) is easy to administer in acute cases and is successful in more than 80 % of cases. All vaginal preparations of polyenes, imidazoles and ciclopirox olamine and oral triazoles (fluconazole, itraconazole) are equally effective ([Table 4]), however oral triazoles should not be administered during pregnancy according to the manufacturers. Candida glabrata is not sufficiently sensitive to the usual dosages of antimycotic agents approved for gynecological use. In other countries vaginal suppositories of boric acid (600 mg, 1–2 times daily for 14 days) or flucytosine are recommended. Boric acid treatment is not allowed in Germany and flucytosine is not available. 800 mg oral fluconazole per day for 2–3 weeks is therefore recommended in Germany. Due to the clinical persistence of Candida glabrata despite treatment with high-dose fluconazole, oral posaconazole and, more recently, echinocandins such as micafungin are under discussion; echinocandins are very expensive, are not approved for this indication and are not supported by clinical evidence of their efficacy. In cases of vulvovaginal candidosis, resistance to Candida albicans does not play a significant role in the use of polyenes or azoles.