- Vulvovaginal (most common)

-Oropharyngeal (most common)

- Esophageal (less common)

Infections in individuals w/ or w/o symptoms who have positive vaginal cultures for candida species. 

Symptoms common in women (often non-specific symp)

Sporadic

susceptible to antifungal tx regardless of duration of tx 

- Recurrent VVC

- Severe dz

- Non-albicans candidiasis (don't know unless cultured)

- Abnormal host factors (DM, immunocompromised, pregnancy)

- Host factors

- Microorganism

- Pharmacotherapy (past hx)

C. albicans 

Others not as common: C. glabrata, C. tropicalis 

- Previous episode (risk for recurrence)

- sexual contact

- Contraceptive use including diaphragm w/ spermicide, contraceptive sponge, intrauterine device 

- Oral contraceptive use (not as high w/ lower estrogen-dose OC)

- Age after 20 

- Abx use, tight clothing, Impaired cell mediated immunity 

Vaginal pH- normal, saline and 10% KOH microscopy-blastospores or pseudohyphae.

Candida cultures not recommended unless classid signs & symp w/ normal vaginal pH and microscopy is inconclusive or recurrence is suspected 

False, does not require treatment 

What are non-pharmacological tx for VVC?

OTC products: Topical:

Butoconazole, clotrimazole, miconazole, ticonazole 

Rx/topical:Nystatin, terconazole 

PO products: Fluconazole 150 mg 1 tab * 1 d

Po vs. topical no significant difference in cure rate 

Duration of therapy not critical issue

How is complicated VVC treatment different from uncomplicated VVC tx?

Longer duration of therapy ~10-14 d, more aggressive tx plan
VVC in patient w/ immunosuppression, DM, pregnancy  

Recurrent: > 4 episodes/ 12 months 

Intensive therapy followed by "suppressive" therapy.

Fluconazole 150 mg PO QD * 10 d, then 150 mg PO Q week * 6 months, or itraconazole 100 mg PO q 24h * 6 months or Clotrimazole suppository 500 mg q week * 6 months 

Infection of oral mucosa---"thrush"

May extend into esophagus--esophageal candidiasis 

Treat for 7-14 d 

Clotrimazole 10 mg troche. hold 1 troche 15-20 minutes for slow dissolution 4-5 times daily 

Nystatin 100,000 units/ml suspension, 5 ml swish and swallow QID

Fluconazole 100 mg Po QD

Itraconazole 10mg/ml solution, 200 mg QD

Posaconazole 40 mg/ml suspension, 100 mg BID on day 1, then 100 mg QD w/ full meal 

Treat for >= 14 days 

Itraconazole 10 mg/ml solution, 200-400 mg QD

Voriconazole 200 mg tab: 100 mg BID (on empty stomach)

Posaconazole 10 mg.ml suspension, 400 mg BID

Amphotericin B 100 mg/ml suspension, 1-5 ml swish and swallow 4-5 times QD

Amphotericin B deoxycholate 50 mg injection, 0.3-0.7 mg/kg/d

Caspofungin 50 mg IV QD 

Requires systemic therapy

Longer duration of tx 14-21 days 

Fluconazole 100-400 mg PO daily 

Itraconazole is alternative 

Voriconazole & caspofungin reserved for refractory cases 

True, Women who have more receptos have more colonization.

Appropriate receptors for attachement to vaginal mucosa must be present in epithelial tissue 

- Use of steroids and Abx

- Dentures

- Xerostomia caused by drugs (TCAs, phenothiazines), chemo, radiotherapy

- Smoking

- disruption of oral mucosa (chemo and radio, ulcers, endotracheal intubation trauma, burns)

Drugs (cytotoxic agents, corticosteroids, immunosuppressants, PPIs)

Environemental chemicals (pesticides)

Age- neonates or elderly

HIV infection/AIDS

Diabetes

Malignacies (leukemia, head and neck cancer)

Neonates, patients w/ HIV or cancer, debilitated elderly, pts on broad-spectrum Abx or steroid inhalers, pts w/dry mouth from various causes, smokers

Its a creamy, white, curd-like patches over tongue & other mucosal surfaces 

Can include diffuse erythema and white patches on the surfaces of buccal mucosa, throat, tongue or gums

Constitutional signs absent 

Dysphagia, odynophagia, retrosternal chest pain 

Constitutional signs may be present (fever)

Upper GI endoscopy

Cultures to assess for resistant candida spp is warranted 

Treat for 21-28 days:

Itraconazole 10 mg/ml sol: 200-400 mg QD

Voriconazole 200 mg PO: 200 mg BID

Caspofungin 50 mg IV QD

Micafungin 150 mg IV QD

Anidulafungin 100 mg IV on day 1, then 50 mg IV QD

Ampho B deoxycholate 0.3-0.7 mg/kg/day IV or lipid based 3-5 mg/kg/day IV 

Topical antifungal therapy * 2-4 weeks (mild)

Terbinafine and butenafine 

Severe with nail involvement: Fluconazole or terbinafine PO 

Scrotum and penis usually spared

Topical preffered: clotrimazole, terbinafine, butenafine 

If spreads to lower thigh/buttock: Itraconazole or terbinafine PO

Topical steroids (2.5% hydrocortisone) may be used for pruritis relief * 2-3 days 

PO terbinafine, itraconazole

Alternative: Griseofulvin

Shampoo daily for removal of scales (ketoconazole, selenium sulfide)

fungal infx of nails, toenails>>fingernails

Trichophyton rubrum

Trichophyton mentagrophytes

Less common: molds and yeasts

high failure and recurrence rates

Terbenafine 250 mg QD PO (1st line) 

Itraconazole PO (alternative)

Duration: 12 weeks (toenail), 6 weeks (fingernail)

Long duration of therapy-adhrence is a must

nails may not normalize w/ tx

Toenail more difficult to treat than fingernail

May need to remove nail and treat w/ antifungal for adequate duration 

- Superficial infx

- Partial area of nail late involved

- Few nails involved

- Confined to distal edge of nail 

- Systemic tx CI

Use: Ciclopirox 8% lacwuer apply solution at night for up to 48 wks