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Case History

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Image not available. A 25-year-old woman comes complaining of a vaginal discharge, itching and soreness. From the history, a diagnosis of vulvovaginal candidiasis (VVC), otherwise referred to as vaginal thrush, is likely. She has been using a cream that she obtained from the chemist with some relief, but reports that she has similar symptoms every few months.

How would you confirm a diagnosis of VVC?

What is the differential diagnosis?

What are potential precipitating factors?

What are the treatment options?

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Background

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Image not available. VVC is the second most common cause of vaginitis and vaginal discharge after bacterial vaginosis and is characterized by abnormal colonization of the vagina by yeast cells. The lifetime incidence of VVC is estimated to be between 50% and 75%.1

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The commonest causative agent is Candida albicans, accounting for 80%–95% of infections, and Candida glabrata is responsible for a further 5%.1 Other yeast infections are less common and are generally more difficult to treat. Candida is often present in the vagina of asymptomatic women and becomes pathological following a change in the vaginal environment. Infection may be classified as 'acute' or 'recurrent'. Recurrent candidiasis is defined as four or more episodes over the period of a year and occurs in less than 5% of women of reproductive age.2

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How would you confirm a diagnosis of VVC?

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Diagnosis may be clinical or confirmed by laboratory testing. Typical symptoms include a vaginal discharge, itching, soreness, superficial dyspareunia and sometimes dysuria. Signs may include a non-offensive vaginal discharge, vulval and vaginal erythema, fissuring, oedema and the presence of satellite lesions.

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If a diagnosis cannot be reached on clinical grounds alone, or symptoms become recurrent, a high vaginal swab may be taken from the anterior fornix or lateral vaginal walls. Microscopy looking for spores and/or pseudohyphae detects up to 70% of cases,1 and culture is helpful to exclude other diagnoses or for identification of resistant species.

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What is the differential diagnosis?

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Differential diagnosis includes bacterial vaginosis, sexually transmitted infections (such as trichomoniasis, gonorrhoea, herpes, chlamydia), normal physiological discharge, local irritants, skin conditions (eczema, psoriasis), atrophic vaginitis (in post-menopausal women), foreign body (such as a retained tampon) and, rarely, malignancy (see Case 32: Vaginal Discharge). Clearly, individual symptoms and signs will vary.

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What are potential precipitating factors?

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VVC is more common in women of reproductive age as Candida albicans flourishes in an oestrogen-rich environment. For this reason, it is also more common in pregnancy.

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Controversy exists regarding the significance of certain forms of contraception in relation to recurrent VVC. There is no good evidence of an association with the oral contraceptive pill; condoms probably do not cause VVC per se, but certain spermicides may increase the likelihood of infection by harming the natural vaginal flora; ...

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