Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

---

1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Vulvovaginal Candidiasis
     
     Vulvovaginal candidiasis (VVC) is caused by C. albicans or,
occasionally, by other Candida spp, Torulopsis sp, or other yeasts.
An estimated 75% of women will experience at least one episode of
VVC during their lifetime, and 40%-45% will experience two or more
episodes. A small percentage of women (probably less than 5%)
experience recurrent VVC (RVVC). Typical symptoms of VVC include
pruritus and vaginal discharge. Other symptoms may include vaginal
soreness, vulvar burning, dyspareunia, and external dysuria. None
of these symptoms is specific for VVC. VVC usually is not sexually
acquired or transmitted.

Diagnostic Considerations
     A diagnosis of Candida vaginitis is suggested clinically by
pruritus in the vulvar area together with erythema of the vagina or
vulva; a white discharge may occur. The diagnosis can be made when
a woman has signs and symptoms of vaginitis, and when a wet
preparation or Gram stain of vaginal discharge demonstrates yeasts
or pseudohyphae, or when a culture or other test yields a positive
result for a yeast species. Vaginitis solely because of Candida
infection is associated with a normal vaginal pH ( less than or
equal to 4.5). Use of 10% KOH in wet preparations improves the
visualization of yeast and mycelia by disrupting cellular material
that may obscure the yeast or pseudohyphae. Identifying Candida in
the absence of symptoms should not lead to treatment, because
approximately 10%-20% of women normally harbor Candida spp and
other yeasts in the vagina. VVC may be present concurrently with
STDs.

Treatment
     Topical formulations provide effective treatment for VVC. The
topically applied azole drugs are more effective than nystatin.
Treatment with azoles results in relief of symptoms and negative
cultures among 80%-90% of patients after therapy is completed.

Recommended Regimens -
     The following intravaginal formulations are recommended for
the treatment of VVC.

     Butoconazole 2% cream 5 g intravaginally for 3 days;*
                            or
     Clotrimazole 1% cream 5 g intravaginally for 7-14 days;**
                            or
     Clotrimazole 100 mg vaginal tablet for 7 days;**
                            or
     Clotrimazole 100 mg vaginal tablet, two tablets for 3 days;
                            or
     Clotrimazole 500 mg vaginal tablet, one tablet single
     application;
                            or
     Miconazole 2% cream 5 g intravaginally for 7 days;* **
                            or
     Miconazole 200 mg vaginal suppository, one suppository for 3
     days;*
                            or
     Miconazole 100 mg vaginal suppository, one suppository for 7
     days;* **
                            or
     Tioconazole 6.5% ointment 5 g intravaginally in a single
     application;*
                            or
     Terconazole 0.4% cream 5 g intravaginally for 7 days;
                            or
     Terconazole 0.8% cream 5 g intravaginally for 3 days;
                            or
     Terconazole 80 mg suppository, 1 suppository for 3 days.*

     Although information is not conclusive, single-dose treatments
should probably be reserved for cases of uncomplicated
mild-to-moderate VVC. Multi-day regimens (3- and 7-day) are the
preferred treatment for severe or complicated VVC.

     Preparations for intravaginal administration of both
miconazole and clotrimazole are now available over-the-counter (OTC
{nonprescription}), and women with VVC can choose one of those
preparations. The duration for treatment with either preparation is
7 days. Self-medication with OTC preparations should be advised
only for women who have been diagnosed previously with VVC and who
experience a recurrence of the same symptoms. Any woman whose
symptoms persist after using an OTC preparation or who experiences
a recurrence of symptoms within 2 months should seek medical care.

* These creams and suppositories are oil-based and may weaken latex
condoms and diaphragms. Refer to product labeling for further
information.

** Over-the-counter (OTC) preparations.

Alternative Regimens
     Several trials have demonstrated that oral azole agents such
as fluconazole, ketoconazole, and itraconazole may be as effective
as topical agents. The optimum dose and duration of oral therapy
have not been established, but a range of 1-5 days of treatment,
depending on the agent, has been effective in clinical trials. The
ease of administration of oral agents is an advantage over topical
therapies. However, the potential for toxicity associated with
using a systemic drug, particularly ketoconazole, must be
considered. No oral agent is approved currently by the FDA for the
treatment of acute VVC.

Follow-Up
     Patients should be instructed to return for follow-up visits
only if symptoms persist or recur. Women who experience three or
more episodes of VVC per year should be evaluated for predisposing
conditions (see Recurrent Vulvovaginal Candidiasis).

Management of Sex Partners
     VVC is not acquired through sexual intercourse; treatment of
sex partners has not been demonstrated to reduce the frequency of
recurrences. Therefore, routine notification or treatment of sex
partners is not warranted. A minority of male sex partners may have
balanitis, which is characterized by erythematous areas on the
glans in conjunction with pruritus or irritation. These partners
may benefit from treatment with topical antifungal agents to
relieve symptoms.

Special Considerations

Allergy or Intolerance to the Recommended Therapy
     Topical agents are usually free of systemic side effects,
although local burning or irritation may occur. Oral agents
occasionally cause nausea, abdominal pain, and headaches. Therapy
with the oral azoles has been associated rarely with abnormal
elevations of liver enzymes. Hepatotoxicity secondary to
ketoconazole therapy has been estimated to appear in 1:10,000 to
1:15,000 exposed persons. Clinically important interactions may
occur when these oral agents are administered with other drugs,
including terfenadine, rifampin, astemizole, phenytoin, cyclosporin
A, coumarin-like agents, or oral hypoglycemic agents.

Pregnancy -
     VVC is common during pregnancy. Only topical azole therapies
should be used for the treatment of pregnant women. The most
effective treatments that have been studied for pregnant women are
clotrimazole, miconazole, butoconazole, and terconazole. Many
experts recommend 7 days of therapy during pregnancy.

HIV Infection -
     Acute VVC occurs frequently among women with HIV infection and
may be more severe for these women than for other women. However,
insufficient information exists to determine the optimal management
of VVC in HIV-infected women. Until such information becomes
available, women with HIV infection and acute VVC should be treated
following the same regimens as for women without HIV infection.


Recurrent Vulvovaginal Candidiasis
     
     RVVC, usually defined as three or more episodes of symptomatic
VVC annually, affects a small proportion of women (probably less
than 5%). The natural history and pathogenesis of RVVC are poorly
understood. Risk factors for RVVC include diabetes mellitus,
immunosuppression, broad spectrum antibiotic use, corticosteroid
use, and HIV infection, although the majority of women with RVVC
have no apparent predisposing conditions. Clinical trials
addressing the management of RVVC have involved continuing therapy
between episodes.

Treatment
     The optimal treatment for RVVC has not been established.
Ketoconazole 100 mg orally, once daily for up to 6 months reduces
the frequency of episodes of RVVC. Current studies are evaluating
weekly intravaginal administration of clotrimazole, as well as oral
therapy with itraconazole and fluconazole, in the treatment of
RVVC. All cases of RVVC should be confirmed by culture before
maintenance therapy is initiated.

     Although patients with RVVC should be evaluated for
predisposing conditions, routinely performing HIV testing for women
with RVVC who do not have HIV risk factors is unwarranted.

Follow-Up
     Patients who are receiving treatment for RVVC should receive
regular follow-up to monitor the effectiveness of therapy and the
occurrence of side effects.

Management of Sex Partners
     Treatment of sex partners does not prevent recurrences, and
routine therapy is not warranted. However, partners with
symptomatic balanitis or penile dermatitis should be treated with
a topical agent.

Special Considerations

HIV Infection -
     Insufficient information exists to determine the optimal
management of RVVC among HIV-infected women. Until such information
becomes available, management should be the same as for other women
with RVVC.

---