Vulvovaginal Candida Infections & Boric Acid Treatments Author: Rebecca O’Grady BPharm, GradCertPharmPrac, MPS AFTER COMPLETING THIS Vulvovaginal candida (VVC) infections are common in women, with ACTIVITY, PHARMACISTS Candida albicans the most common species responsible. This article SHOULD BE ABLE TO: discusses treatment approaches to vaginal thrush, with special 1. List the different emphasis on treatment of the most common atypical candida species pathogens that commonly isolated in VVC, Candida glabrata. cause vulvovaginal patients with Candida glabrata candidiasis Introduction the most common atypical 2. List the treatment options Vulvovaginal candida (VVC) species.3 There are a variety of for vulvovaginal candidiasis infections are a common health medical conditions, medications 3. Describe methods used problem for women, which cause and lifestyle factors which have in the preparation of significant morbidity, with over been shown to increase the risk compounded boric acid 75% of women affected at least 1,2 of developing a VVC infection.8,16 treatments once throughout their lifetime. Approximately 40-50% of women These include:8,16 will experience a second VVC • Diabetes 6 • Immunosuppressant The 2016 Standards addressed infection. These infections can medications by this activity include: 1.4, 1.5, affect both the physical and 2 • Pregnancy 2.1, 2.2, 2.3, 3.1, 3.3, 3.4. emotional health of women. In Western countries studies • Broad spectrum antibiotic use have shown that candida and • Skin conditions including bacteria are the most common vulval psoriasis causes of vaginal infections.5,6 • Tight synthetic clothing First published in the Australian Candida are a family of yeasts Journal of Pharmacy online which inhabit the human VVC infections are most version. 1st February 2019. gastrointestinal and genital tract.7 commonly diagnosed through Reproduced and distributed VVC infections occur when there symptoms however a swab by the Medisca Group of is an overgrowth of candida should be taken to determine the companies with the permission within the vulvovaginal area.3 species of candida.3 Symptoms of of the publisher. Candida albicans is the most VVC infections include:8 common species responsible for VVC infections.1,2,3 However, Common symptoms atypical candida species are • Itch (the most common) isolated in approximately 5% of • Discharge that is often thick, white, and odourless (similar Complicated infections classified if complication is suspected. to cottage cheese), however as those which are infected Women with recurrent thrush can be watery or smooth. with other Candida species, must be referred to a doctor. The amount of discharge present with severe symptoms, This is of particular importance is variable and may be recurrent episodes (≥ 4 per 12 as C. glabrata seems to develop negligible. months), and in patients with co- resistance to many drug classes, Less common symptoms conditions including pregnancy, including the azole antifungals, • Soreness uncontrolled diabetes, and although the mechanism of why • Swelling and redness immunosuppression.8 resistance develops is not well • Burning understood22. This means that • Vulvar dysuria Misdiagnosis is a common treatment with over the counter • Dyspareunia (painful sexual occurrence when patients present (OTC) antifungals is unlikely to intercourse) with vaginal symptoms.8 As per treat a VVC infection caused by C. the Therapeutic Guidelines, a glabrata, and patients presenting VVC infections are classified as swab should be taken before with recurrent infections could uncomplicated or complicated.8 starting any treatment, to isolate potentially have an infection Uncomplicated infections and determine the Candida caused by C. glabrata which they are more than likely due to species responsible for the are ineffectively treating with OTC C. albicans, they present VVC infection, and confirm antifungals. sporadically with infrequent the diagnosis.3 Pharmacists episodes (≤3 per 12 months), with should encourage patients Treatments are available over mild-to moderate symptoms.8 to consult with their doctor the counter (OTC) as Pharmacist Diagram 1. Treatment approach for vaginal thrush: A summary8 ©Pharmaceutical Society of Australia. Reproduced with permission 2018 Only (Schedule 3) medications.1 treatment for vaginal thrush.8 This treatment options as outlined in Scheduling these medications flow chart also outlines when the the Therapeutic Guidelines and as OTC, allows ease of access patient should be referred to their the APF 24. to treatment by patients and GP for diagnosis and treatment increases autonomy for self- (Diagram 1.).8 The efficacy of the commercially diagnosis. However, there available treatment options for is the risk of misdiagnosis Due to this ease of access to the treatment of C. albicans with consequential incorrect treatment, exact infection is supported by considerable treatment choice.1 Studies have rate numbers are difficult to evidence. In contrast, there shown that isolation swabs taken determine, as there is a lack of is a lack of studies available after a patient has used antifungal recording and reporting of the comparing the different treatment commonly report false condition.1,3 treatment options, and treatment negatives whilst the patient is still duration for treating vulvovaginal presenting with symptoms.3 Treatment options candida infections in general.3 There is a large variety of both The Australian Pharmaceutical topical and oral treatment If a patients sexual partner Formulary and Handbook (APF options available in Australia for is presenting with symptoms 24) lists a stepwise treatment the treatment of VVC infections.3, they need to be referred for approach for pharmacists to 8 confirmation of infection before follow when recommending Table 1 is a combination of the treatment is started.8 Candida Table 1: Treatment options for Vaginal Thrush3,8 ACTIVE DOSAGE STRENGTH/ DURATION FREQUENCY ADVERSE PREGNANCY TREATMENT INGREDIENT FORM CONCENTRATION OF OF DOSE EFFECTS AND LINE TREATMENT BREASTFEEDING Clotrimazole Vaginal cream 1% 6 nights One applicator full daily at bedtime Clotrimazole Vaginal cream 2% 3 nights One applicator full daily at bedtime Clotrimazole Vaginal cream 10% 1 night One applicator full daily at Burning, Pregnancy bedtime stinging, Category A First line itching, Safe to use in treatment Clotrimazole Vaginal 100mg 6 nights One pessary erythema breastfeeding suppository/ daily at pessary bedtime Clotrimazole Vaginal 500mg 1 night One pessary suppository/ daily at pessary bedtime Miconazole Vaginal cream 2% 7 nights One applicator full daily at bedtime Nystatin Vaginal cream 100 000 units/5g 14 nights One applicator Well Pregnancy Second line full daily at tolerated Category A treatment. bedtime Safe to use in Less effective breastfeeding than the azoles Fluconazole Oral capsule 150mg 1 day Single oral dose Nausea, Pregnancy Use if topical vomiting, category D therapy is not diarrhoea, Considered safe tolerated or headache, in breastfeeding woman prefers dizziness, oral treatment dyspepsia pathogenic species include bedtime for 7-14 days.3,4,6 The candidiasis caused by Candida C. albicans, C. dubliniensis, C. most common treatment plan glabrata and other non-albicans tropicalis, C. parapsilosis, C. being 600 mg once daily at species orthopsilosis, C. metapsilosis, bedtime for 14 days.3,4,6 Reported C. famata, C. lusitaniae, C. effectiveness of intravaginal boric Size #0 capsules have a volume guilliermondii, C. krusei, C. acid treatment for VVC infections of 0.68 mL and size #00 capsules glabrata, C. kefyr, C. norvegensis, varies between 70-98%.4,6,11,16 have a volume of 0.91 mL. C. inconspicua and C. lipolytica.18 Reported side effects include Pharmacists will need to carry out However only 5 of these species, erythema, burning sensation packing statistic calculations to C. albicans, C. glabrata, C. and watery discharge, however determine the most appropriate tropicalis, C. parapsilosis, and C. those reported are mild and size capsule for their preparation. krusei, are responsible for over infrequent. Intravaginal boric acid These calculations will need 90% of candida infections.18 is mostly well tolerated.4,6 There to be repeated each time a is a lack of safety data for the use new lot of boric acid powder is Candida glabrata of boric acid vaginal treatment sourced by the pharmacy. If after Candida glabrata, previously in pregnant women, therefore it determining these calculations, named Torulopsis glabrata, is an should be avoided where possible part of the capsule volume atypical form of candida causing in pregnancy.3 remains empty, an excipient filler VVC infections. When C. glabrata is required to bring the fill up to is isolated, intravaginal boric A number of studies have shown 100%. Cellulose is an appropriate acid treatment is the effective effectiveness in the use of 600 filler to choose when preparing treatment of choice.3,4,6 Boric mg once daily at bedtime for vaginal capsule preparations.19 acid has bacteriostatic and 5 nights, whilst the woman is Capsules can be filled by hand or fungistatic properties, rather than menstruating, as a preventative by using a capsule filling machine. fungicidal properties, although measure for women with Clear capsule shells composed of the exact mechanism of action is recurrent infections.6,13,14 This either gelatin or cellulose should unknown.4,10 Vaginal acidification treatment is repeated every be chosen to compound the causing cell membrane month for 4-6