[Review of the latest treatments of vulvovaginal mycoses: role of fenticonazole nitrate (Lomexin) in their treatment]

Candidal vulvovaginitis result from the deficiency of hort defense mechanisms in front of the activity factors of candida. Filamentation and then adhesion of candida to vaginal mucosa is the most important step in the process of infection. The principal virulence factors of candida are its genotypical and phenotypical instability as well as proteinase secretion facilitating adhesion and vaginal mucosa invading. Hort defense mechanisms are essentially constituted by vaginal flora and local cellular immunity. A weakening even moderate of this immunity can favor the spontaneous transformation from asymptomatic colonization to symptomatic vaginitis. The most utilized treatments are imidazol derivates in short courses. The fenticonazole nitrate has the particularity and the recently discovered advantage over the other agents available in single dose regimen to inhihate in vitro the proteinase secretion in a dose dependent manner. The different clinical studies carried out in comparative or non comparative studies have demonstrated its efficiency and tolerance. The most recent studies stress the swiftness of symptoms disappearance.

Vaginal colonization or infection with Candida albicans in human immunodeficiency virus-infected women during pregnancy and during the postpartum period. Women and Infants Transmission Study Group

We evaluated the relationship between immunologic status and vaginal colonization or infection with Candida albicans for 605 women enrolled in a multicenter, prospective cohort study of mother-to-infant transmission of human immunodeficiency virus type 1 (HIV-1). A low CD4+ lymphocyte level (< 14% vs. > or = 14%, which corresponds to an absolute count of approximately 200 x 10(6)/L) was associated with a two- to fivefold increased likelihood of vaginal colonization (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.01-5.19) and vaginal candidiasis (OR, 3.08; 95% CI, 1.21-7.71) during pregnancy and during the postpartum period (OR, 2.98; 95% CI, 1.51-5.88 and OR, 5.45; 95% CI, 1.73-16.6, respectively). These associations persisted in multivariate logistic regression analyses. No associations with CD8+ lymphocyte levels or CD8+ CD38+ or other lymphocyte subset levels were found after adjustment for CD4+ cell level and other covariates. However, postpartum (but not antepartum) antibiotic use and pregnancy were also associated with vaginal colonization and candidiasis (P < or = .001 for each). Vaginal candidiasis was not associated with an increased risk of mother-to-infant transmission of HIV-1; however, a related, more inclusive variable, clinical vaginitis or vaginosis of any etiology at the last antepartum visit, was associated with mother-to-infant transmission (OR, 1.92; 95% CI, 1.07-3.43). These findings emphasize the complex, multifactorial nature of vaginal candidiasis and highlight the need for safe and effective treatment and prevention strategies for women with advanced HIV infection.

Recurrent vulvovaginal candidiasis associated with long-term tamoxifen treatment in postmenopausal women

BACKGROUND

Symptomatic vulvovaginal candidiasis is rare in postmenopausal subjects because of the estrogen-dependence of this infection. Tamoxifen, a breast-cancer cell estrogen-antagonist, has not previously been reported to predispose to vulvovaginal candidiasis.

CASES

Three postmenopausal women, age range 60-81 years (mean 71), were identified with recurrent vulvovaginal candidiasis. In all three cases, new onset of recurrent vulvovaginal candidiasis followed daily tamoxifen therapy. The duration of prior tamoxifen therapy was 1-7 years (mean 3.5). One patient had diabetes mellitus, an additional risk factor for vulvovaginal candidiasis. In all three patients, Candida glabrata was identified as the causal pathogen, although in two patients symptomatic episodes caused by Candida albicans also occurred. In all cases, diagnosis was easily established using conventional investigations, and eradication of vulvovaginal candidiasis was possible without cessation of tamoxifen.

CONCLUSION

Long-term tamoxifen treatment may be complicated by recurrent vulvovaginal candidiasis in postmenopausal women.

Immunopathogenesis of recurrent vulvovaginal candidiasis

Recurrent vulvovaginal candidiasis (RVVC) is a prevalent opportunistic mucosal infection, caused predominantly by Candida albicans, which affects a significant number of otherwise healthy women of childbearing age. Since there are no known exogenous predisposing factors to explain the incidence of symptomatic vaginitis in most women with idiopathic RVVC, it has been postulated that these particular women suffer from an immunological abnormality that prediposes them to RVVC. Because of the increased incidence of mucosal candidiasis in individuals with depressed cell-mediated immunity (CMI), defects in CMI are viewed as a possible explanation for RVVC. In this review, we attempt to place into perspective the accumulated information regarding the immunopathogenesis of RVVC, as well as to provide new immunological perspectives and hypotheses regarding potential immunological deficiencies that may predispose to RVVC and potentially other mucosal infections by the same organism. The results of both clinical studies and studies in an animal model of experimental vaginitis suggest that systemic CMI may not be the predominant host defense mechanism against C. albicans vaginal infections. Rather, locally acquired mucosal immunity, distinct from that in the peripheral circulation, is now under consideration as an important host defense at the vaginal mucosa, as well as the notion that changes in local CMI mechanism(s) may predispose to RVVC.

Is vulvovaginal candidiasis an AIDS-related illness?

Early in the AIDS epidemic, retrospective studies reported that vaginal candidiasis occurred more frequently in women who were infected with human immunodeficiency virus (HIV) than in those who were not infected. Some investigators suggested that new onset or recurrent vaginal candidiasis might identify HIV-infected individuals and predict the course of AIDS in women already known to be infected. In this article, studies of vaginal candidiasis in HIV-infected women are examined, and several observations are made. First, early studies were small and likely reflected biased populations. Second, adherence to previously accepted diagnostic criteria for vaginal candidiasis was not consistent in these studies. Finally, conclusions about the increased risk of recurrent or chronic candidal vaginitis in HIV-infected women have been promulgated in the medical literature and may have influenced clinical practice even though such statements are not supported epidemiologically. Prospective trials with uninfected community controls should determine the true impact of HIV infection on vulvovaginal candidiasis.

Treatment of bacterial vaginosis: a comparison of oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream

BACKGROUND

Treatment options for bacterial vaginosis are numerous. The purpose of this study was to compare the efficacy of oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream for the treatment of bacterial vaginosis using traditional clinical and laboratory methods, as well as a new DNA probe test. We also determined the percentage of patients receiving each treatment who developed posttreatment vaginal candidiasis, a potential complication of treating bacterial vaginosis.

METHODS

One hundred one women in whom bacterial vaginosis was diagnosed by standard criteria were randomly assigned to receive: oral metronidazole 500 mg twice daily for 1 week, 0.75% metronidazole vaginal gel 5 g twice daily for 5 days, or 2% clindamycin vaginal cream 5 g once daily for 7 days. Women with coexisting vulvovaginal candidiasis or vaginal trichomoniasis were excluded. Tests of cure by vaginal saline wet prep and potassium hydroxide microscopic examinations, Gram's stain, pH and DNA probe tests for Gardnerella vaginalis and Candida species were scheduled 7 to 14 days following treatment.

RESULTS

There were no statistically significant differences in cure rates for oral metronidazole (84.2%), metronidazole vaginal gel (75.0%), or clindamycin vaginal cream (86.2%) (chi 2 = 1.204, df = 2, P = .548) using traditional clinical and laboratory criteria. Cure rates were lower based on DNA testing, indicating that Gardnerella vaginalis may remain after a clinical cure. This would explain cases of recurrent disease. Posttreatment vulvovaginal candidiasis was experienced by 12.5% of subjects treated with oral metronidazole, 14.8% of subjects treated with clindamycin vaginal cream, and 30.4% of subjects treated with metronidazole vaginal gel (chi 2 = 2.607, df = 2, P = .272).

CONCLUSIONS

Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream achieved nearly equivalent cure rates for the treatment of bacterial vaginosis. Patients treated with these agents experienced similar rates of posttreatment vulvovaginal candidiasis, but those using the intravaginal products reported being more satisfied with the treatment.

[Recurrent vulvovaginal mycoses]

The treatment of recurrent vulvovaginal fungal infections is difficult. Pathogenic mechanisms are discussed. Available pharmacologic treatments and their mechanisms of action are reviewed. Patients clearly prefer oral treatment. Ketoconazole is toxic. Only topical or nonabsorbed oral agents can be used during pregnancy. Agents absorbed via the digestive tract can be used in women who use effective contraceptive methods. Published data demonstrate that trifluconazole (which has not yet been granted a license in France) is potent and less toxic than ketoconazole, and that recurrences at discontinuation of this drug are less common. A few hypotheses for future research are presented.

Sexual behavior of women with repeated episodes of vulvovaginal candidiasis

One hundred and two women with a history of a median of six episodes of vulvovaginal candidiasis (VVC) and 204 age-matched controls participated in a structured in-depth interview on sexual behavior. Mean and median ages of the two groups were 26.7 and 26 years, respectively. Sexual characteristics, associated with VVC in crude analyses, were adjusted in multifactorial analyses for coital frequency, experience of casual sex, vaginal irritation, smoking, alcohol habits, and having a steady partner. In addition, education, as a measure of socioeconomic status, was added in the multifactorial analyses. VVC was not associated with multiple sexual partners or ever-experience of causal sex. Sexual variables that remained significant or were of borderline significance after adjustment were: age at first intercourse (p = 0.001), causal sex partners the previous month (odds ratio (OR) = 3.1), sex during menstruation (OR = 1.7), regular oral sex (OR = 2.4), experience of anal intercourse ever (OR = 2.4), oral intercourse the last month (OR = 3.1), and frequency of oral intercourse (p = 0.02). Thus, the study indicates that certain sexual activities are associated with repeated episodes of VVC.

Modulation of cell surface-associated mannoprotein antigen expression in experimental candidal vaginitis

The monoclonal antibody (MAb) AF1 recognizes an oligosaccharide epitope present on highly immunogenic and immunomodulatory mannoproteins (MP) of Candida albicans. The expression of this epitope (AF1-MP) during experimental candidal vaginitis was studied in two strains of C. albicans (3153 and CA-2) which were equally vaginopathic but differed in the mode of hypha formation in the vagina. In both strains, immunofluorescence of vaginal samples, taken 1 h after challenge, revealed an intense, MAb AF1-specific labelling of the yeast cells. This labelling was very scarce in fungal cells taken at 24 h and on subsequent days during the development of filamentous forms. Electron-microscopic gold immunolabelling observations showed that molecules carrying AF1-MP spanned the entire cell wall in the initial yeast cells but were absent on the cell surface and in the outermost, capsular layer of the cell wall of the germ tubes and filamentous forms. In both strains, at any time and for any form of intravaginal growth, AF1-MP was clearly expressed in the cytoplasm and cytoplasmic vesicles, and was fully incorporated into the inner layers of the cell wall. As seen by immunofluorescence, the vaginal fluid from C. albicans-infected rats did not hinder the expression of AF1-MP on the yeast cells surface in vitro. In electron-microscopic gold immunolabelling, a hypha-specific MAb (3D9) labelled the surface of the hyphal but not of the yeast cells of C. albicans harvested from rat vagina. Overall, these data strongly suggest that cell surface expression of MP antigen is modulated during intravaginal growth and morphogenesis of C. albicans.

Vaginal yeast infections in diabetic women

Two hundred and three diabetic women (89 with and 114 without genital symptoms) were examined for the presence of yeasts and Trichomonas vaginalis. Yeasts were isolated from the vaginas of 35.5% of patients and were more common in the symptomatic group (48.0%) than the asymptomatic group (25.4%; P < 0.05). Candida albicans was isolated from 12.8% of all patients and showed a significant association with pruritus vulvae (P < 0.05). A significant association was also shown between the presence of yeasts in the rectum and in the vagina. C. glabrata (Torulopsis glabrata) was the commonest yeast species isolated (50.0%), with C. albicans the next most frequent (36.1%). T. vaginalis infection was present in 14.3% of all subjects.

FDA warns frequent yeast infections could be early sign of HIV

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Cytolytic vaginosis: a common cause of cyclic vulvovaginitis

Cytolytic vaginosis (CV) infection is a little recognized but common cause of cyclic vulvovaginal complaints in women of reproductive age. Often misdiagnosed as candidiasis, most women have tried myriad antifungal medications to little or no avail. The history and physical examination is often similar to that seen in women with vaginal candidiasis. However in CV infection there is a luteal phase pattern of symptom recurrence. An astute clinician can make this diagnosis on vaginal microscopic examination and by meticulously ruling out other infections. Management consists of discontinuing all antifungal agents, using pads instead of tampons with menses, and taking baking soda sitz baths. Baking soda douches may also be helpful. As clinicians become familiar with CV infection, more women will be diagnosed and managed appropriately, leading to a long awaited resolution of their chronic vaginal complaints.

Recurrent bacterial vaginosis: association with vaginal sponge use

A hypothesis-generation study was conducted to examine risk factors for bacterial vaginosis recurrences among women participating in a randomized controlled trial of male sexual partner treatment. Of the 140 women enrolled in the trial, 72 had a normal vaginal gram-stained slide at the first follow-up visit and were included in this analysis. Nineteen of the 72 (26.2%) women developed a bacterial vaginosis recurrence documented by a vaginal gram-stained slide during the 6-week follow-up period. Of the 19 women, 4 of 6 sponge users (66%) developed a bacterial vaginosis recurrence (RR 2.93, 95% CI: 1.43-6.02). Logistic regression analysis supported the association between sponge use and bacterial vaginosis recurrences (adjusted RR 2.71, 95% CI: 1.06-6.99) but revealed that an apparent protective effect of diaphragm use was due to the confounding effect of sexual partner treatment. Our hypothesis is that bacterial vaginosis recurrences may be due to factors other than sexual transmission, such as sponge use. Further studies are needed to examine risk factors for bacterial vaginosis recurrences. In the interim, physicians might suggest another form of contraception to their sponge-using patient with frequent bacterial vaginosis infections.

Risk factors for Candida vulvovaginitis

Although Candida vulvovaginitis occurs commonly, the reasons for its occurrence and recurrence are often unclear. Several potential risk factors have been described, including the recent use of antibiotics and oral contraceptives, the presence of diabetes mellitus, dietary practices, gastrointestinal colonization by the organism, clothing and sanitary protection practices, sexual communicability of the organism, and specific immunological defects. However, the data supporting each of these factors are conflicting, and to date none are predictive of infection. In this review, the data evaluating these potential risk factors are described. From this information, implications for clinical practice are discussed.