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Vulvovaginal candidiasis (VVC), commonly referred to as a yeast infection, is considered the second most prevalent type of vaginal infection.1 VVC can be classified as uncomplicated or complicated based on frequency, symptoms, microbiology, and response to treatment.2 The occurrence of VVC is uncommon prior to menarche; however, 75% of reproductive-age women will experience at least 1 episode of VVC in their lifetime, and 40% to 45% will have 2 or more episodes.1,2 In general, an estimated 80% to 92% of infections are caused by Candida albicans.1,2 Infections also can be caused by other species, however, such as Candida glabrata and Candida tropicalis, and the latter 2 types are often more resistant to treatment.2
Examples of factors that may increase the likelihood of developing a yeast infection include uncontrolled diabetes, pregnancy, high-dose estrogen oral contraceptives, and estrogen replacement therapy.1 Some patients report developing a VVC infection during or after completing treatment with broad-spectrum antibiotics. Patients taking systemic corticosteroids, immunosuppressant agents, or antineoplastic drugs also have reported developing VVC infections.1
Signs and Symptoms
The characteristic symptoms associated with VVC include1,2:
• Abnormal vaginal discharge (ranging from a slightly watery, white discharge to thick, white discharge with no odor)
• Normal pH
• Intense burning, especially upon urination
• Inflammation of the vulvar skin
Patients with a history of recurring episodes of VVC, those with severe symptoms, and those with preexisting medical conditions should be referred for further medical evaluation and treatment.
In selecting a treatment for VVC, the goals of therapy include elimination of the infection, relief from symptoms, and reestablishment of the normal vaginal flora.1 Currently on the market are a variety of OTC products available for the self-treatment of VVC and an at-home diagnostic test to screen for yeast infections including Combe Inc’s Vagisil Screening Kit. Also available are various homeopathic products marketed for the treatment and prevention of yeast infections. According to the Handbook of Nonprescription Drugs, the use of OTC vaginal antifungals is considered to be appropriate for those patients who have had at least 1 previous episode that was medically diagnosed, those patients with VVC whose symptoms are mild to moderate and are consistent with classic VVC symptoms, and those patients with infrequent symptoms (ie, no >3 infections annually and no infections within the last 2 months).1
Currently, OTC vaginal antifungals belong to the imidazole class and contain active ingredients such as butoconazole, clotrimazole, miconazole, and tioconazole. OTC imidazoles are approved by the FDA for the local treatment of VVC and the relief of external vulvar itching and irritation associated with yeast infections and are available in creams for both internal and external use, vaginal suppositories, and tablets to be used for various durations that range from 1 to 7 days.1 Typically, the incidence of adverse effects associated with the use of topical imidazoles are minimal, but can include vulvovaginal itching, burning, and irritation.
Prior to recommending any of these OTC products, pharmacists should assess the appropriateness of self-treatment as well as assess the patient for possible contraindications. Women who are pregnant or breast-feeding should consult their primary health care provider before using any of these products. Patients should be advised about the proper use of these antifungals and adhere to the instructions provided by the manufacturer. It is very important to remind patients to complete the full course of therapy even if symptoms appear to improve.
Discontinuing therapy before the recommended duration is considered the leading cause of recurring episodes of VVC.1 Patients whose symptoms show no signs of improving or worsen should be encouraged to seek immediate medical attention. Examples of key points to cover during patient counseling include1:
• Always wash hands before and after application of selected product.
• Symptoms typically improve within 24 to 48 hours of the initiation of therapy.
• Insert antifungal product once daily, preferably at bedtime because lying down can minimize leakage of product.
• It is important to complete full course of therapy, even during menstrual flow.
• Do not use tampons or douche when using vaginal antifungals.
Rosenthal W, Briggs G. Home Testing and
Monitoring Devices. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 15th
2. Scolaro KL, Braxton KB, and Helms KL. Devices for Home Evaluation of Women's Health Concerns. Medscape Web site. www.medscape.com/viewarticle/571895_1. Accessed April 3, 2009.