Vulvovaginal candidiasis (vvc), also known as a yeast infection, is one of the most common vaginal infections affecting an estimated 75% of women, who report at least 1 episode in their lifetime.1

Self-treatment with OTC antifungal therapy is appropriate in women with infrequent, mild, and uncomplicated infections, according to the CDC.1,2

Recurring episodes may be an indication of an underlying issue, so encourage patients to pursue further medical care from their primary health care providers, as there is a potential for inappropriate therapy.1 For example, research shows that many women have difficulty identifying a VVC episode, and 2 of 3 who purchase OTC VVC antifungals do not really have a yeast infection.1,3,4

Although any woman can develop VVC, certain factors may increase the risk, especially in terms of recurring infections. Factors that may augment the risk of developing VVC include estrogen replacement therapy, high-dose estrogen oral contraceptives, pregnancy, and uncontrolled diabetes.1,3 Some patients also report developing a VVC infection during or after completing treatment with broad-spectrum antibiotics. Moreover, patients taking systemic antineoplastic drugs, corticosteroids, or immunosuppressant agents also have reported developing VVC infections.1,3

Classic signs and symptoms of VVC may include abnormal vaginal discharge, ranging from a slightly watery, white discharge to a thick white discharge with no odor; inflammation of the vulvar skin; intense burning, especially when urinating; itching; a pH greater than 4.5; and soreness.1-3

Patients with a history of recurring episodes of VVC, those with severe symptoms, and women with preexisting medical conditions should be referred for further medical evaluation and treatment.1,3 In general, the goals of therapy for vaginal fungal infections are resolution of infection, restoration of normal vaginal flora, and symptomatic relief. To date, the FDA-approved treatment OTC options for uncomplicated VVC include clotrimazole, miconazole,
and tioconazole, which are available in vaginal creams, suppositories, and tablets.1 Some formulations are available in 1-, 3- and 7-day treatments. Pharmacists should advise patients to adhere to the manufacturer directions and always ask questions about any concerns. Some manufacturers of OTC VVC products also have useful patient education resources, including symptom assessment tools on their websites and other resources about vaginal health.

It is important to remind patients to complete the full course of therapy as indicated by the manufacturer instructions on the selected product, even if symptoms appear to improve. Failure to complete therapy for the recommended duration is considered the leading cause of recurring VVC episodes.1 Patients whose symptoms show no signs of improving or worsen should seek immediate medical attention. During counseling, pharmacists should ensure that patients understand the proper use of OTC products indicated for VVC.

Pharmacists can advise patients to always wash their hands before and after application of the antifungal product; complete the full course of therapy, even during menstruation; insert the product once daily, ideally at bedtime, because lying down can minimize product leakage; not to douche or use tampons when using vaginal antifungals; refrain from intercourse during treatment; and seek medical care if symptoms persist or worsen. They can also let patients know that symptoms typically improve 24 to 48 hours after initiating therapy.1

Conclusion
Pharmacists can educate patients about recommended preventive measures and self-care for VVC. They can also encourage and remind patients to consult their primary health care providers to confirm diagnosis, especially if this is the first occurrence of VVC, and urge those with recurring episodes to seek further medical care to avoid additional complications and rule out other possible causes. Pharmacists can also inform patients about populations who should not self-treat and advise them to seek medical care. These include patients who are pregnant; have a fever or pain in the lower abdomen, back, pelvic area, or shoulder; take pharmacological agents that predispose them to VVC, such as chemotherapy and steroids; and are younger than age 12. It also includes patients with a history of VVC episodes that have occurred more than 3 times per year or in the past 2 months and those with a history of medical conditions that predispose them to VVC, such as an HIV infection or uncontrolled diabetes.1

REFERENCES
  1. Lodise N. Vaginal and vulvovaginal disorders. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 19th ed. American Pharmacists Association; 2018:chap 8.
  2. Vulvovaginal candidiasis. CDC. Updated June 4, 2015. Accessed August 17, 2020. https://www.cdc.gov/std/tg2015/candidiasis.htm.
  3. Vaginal yeast infections. Office on Women’s Health. Updated April 1, 2019. Accessed August 18, 2020. https://www.womenshealth.gov/a-z-topics/vaginal-yeast-infections.
  4. Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, Litaker MS. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol. 2002;99(3):419-425. doi:10.1016/s0029-7844(01)01759-8.