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Research Article | Volume 11 Issue :3 (, 2021) | Pages 68 - 72
Comparative Evaluation of Different Antifungal Regimens for The Treatment of Vaginal Candidiasis
 ,
 ,
1
Assistant Professor, Department of Obstetrics & Gynaecology, Rama Medical College Hospital & Research Centre, Kanpur, Uttar Pradesh. India.
2
Associate professor, Department of pharmacology, Karpagam Faculty of medical science and research , Ottakalmandapam, Coimbatore, Tamilnadu, India.
3
Assistant Professor, Department of Pharmacology, Zydus Medical College & Hospital, Dahod, Gujarat, India.
Under a Creative Commons license
Open Access
DOI : 10.5083/ejcm
Received
June 1, 2021
Revised
July 2, 2021
Accepted
July 21, 2021
Published
Aug. 3, 2021
Abstract

Vaginal candidiasis is a common fungal infection affecting women worldwide. This study compares the effectiveness of different antifungal regimens, including topical and oral formulations, in treating the infection. A randomized clinical trial was conducted on 200 patients diagnosed with vaginal candidiasis. Patients were divided into four groups, each receiving a different antifungal regimen. The outcomes were evaluated based on symptom resolution, fungal clearance, and recurrence rates. Results indicated that while oral fluconazole showed the highest efficacy in symptom relief and fungal eradication, topical azoles were also effective with fewer systemic side effects. This study provides insights into optimizing antifungal therapy for vaginal candidiasis.

Keywords
INTRODUCTION

Vulvovaginal candidiasis (VVC) is a fungal infection that causes inflammation of the vulvar and vaginal epithelium [1]. Up to 75% of women will experience at least one episode of VVC in their lifetime, most commonly during their reproductive years [1,2]. Recurrent vulvovaginal candidiasis (RVVC) is defined as having three or more symptomatic acute episodes of VVC within a 12-month period [3]. Candida albicans is responsible for 85%−95% of VVC cases and the majority of RVVC cases as well. While only 9% of women with VVC develop RVVC [2,4], a large systematic review in 2018 estimated that 138 million women worldwide experience RVVC annually, with this number expected to rise to nearly 158 million by 2030 [2].

 

While most women with RVVC experience recurrent infections for 1–2 years, some may deal with them for 4–5 years or even decades [3]. In addition to the physical discomfort and limitations caused by the symptoms, women with RVVC report a significant reduction in their quality of life [2], along with debilitating psychosocial effects [5]. Many experience increased stress, lower self-esteem, and decreased confidence, and are more likely to suffer from clinical depression. In qualitative interviews, women with RVVC have expressed high levels of anxiety and fear about social interactions, dating, and often avoid sexual activity [6].

 

For the diagnosis of recurrent vulvovaginal candidiasis (RVVC) is a common vaginal commensal, often present without causing infection, so its presence alone is not diagnostic of infection. Acute VVC is defined by signs and symptoms of inflammation, along with the presence of Candida species and the absence of other infectious causes, unless there is coinfection [7]. Symptoms of vaginal infection can include dysuria, vulvar pruritus, pain, swelling, and redness, which may vary from patient to patient [8]. These symptoms are largely nonspecific and should not be used alone for diagnosing VVC, as relying on them without further testing can lead to underdiagnosis, overdiagnosis, or misdiagnosis.

 

The diagnosis of VVC should include testing methods such as microscopy of vaginal discharge, fungal culture, or other tests like polymerase chain reaction (PCR) to identify the presence and species of yeast. Microscopy of vaginal discharge using wet preparation (saline or 10% potassium hydroxide) to detect budding yeasts, pseudohyphae, or hyphae is a commonly used, rapid method to confirm a suspected VVC infection. However, microscopy has limitations, including a sensitivity range of only 40%−70%, and it may be less effective at identifying certain species, such as Candida glabrata, which do not form hyphae or pseudohyphae [9].

 

Fluconazole continues to be the first-line treatment for VVC, with 96% of women reporting improved quality of life; however, 63% of women still experience ongoing infections after completing maintenance therapy [10]. Women with persistent vaginal yeast colonization often face discomfort and anxiety, and there are significant clinical concerns regarding future treatment decisions [11, 12]. Given the high prevalence of VVC, vaginal yeast colonization after standard treatment, and the side effects associated with topical azole antifungal agents, VVC remains a public health issue. Recently, two new drugs—etaconazole and ibrexafungerp—have emerged, offering higher efficacy in treating VVC and a lower risk of side effects [13, 14]. This highlights the need for a literature review to summarize and assess current treatment guidelines and therapeutic options for vulvovaginal candidiasis [15]. The goal of this paper is to present these guidelines and explore new treatment options for VVC.

MATERIALS AND METHODS

Study Design: A prospective, randomized clinical trial was conducted on 200 women diagnosed with vaginal candidiasis.

 

Total Sample size: 200 women diagnosed with vaginal candidiasis. Patients were divided into four treatment groups:

  • Group A: Single-dose oral fluconazole (150 mg)
  • Group B: Seven-day topical clotrimazole (1% cream)
  • Group C: Three-day topical miconazole (2% cream)
  • Group D: Combination therapy (oral fluconazole + topical clotrimazole)

 

Inclusion Criteria

  1. Women aged 18–50 with clinical symptoms of vaginal candidiasis
  2. Positive Candida culture and microscopy
  3. No recent antifungal treatment.
  4. Patients ready to give inform consent
  5. Patient ready to participate in this study.

 

Exclusion Criteria

  1. Pregnancy
  2. Diabetes mellitus
  3. Immunosuppressive conditions
  4. Patients not ready to give inform consent form.

 

Outcome Measures:

  • The patients visiting the gynaecology department's OPD provided details about their symptoms, and the affected area of fungal infection was sent for culture. Symptom resolution was observed on days 7 and 14. Fungal clearance was confirmed through culture results. The study was conducted over a one-month follow-up period.
RESULTS

The study was conducted after obtaining approval from the institutional ethics committee and receiving informed consent from the patients. A total of 200 patients with vulvovaginal candidiasis participated in the study.

 

Table No 1 – Age distribution among patients with vulvovaginal candidiasis

Age Group

Number of patients

Percentage No of patients

18 – 25

46

23.00%

26 – 33

95

47.50%

34 – 41

32

16.00%

42 – 50

27

13.50%

 

Table 2 – Symptoms in  vulovaginal patien

Symptoms

Group A

(50 patients)

Group B

(50 Patients)

Group C

(50 Patients)

Group D

(50 Patients)

Itching or soreness in vagina

50

50

50

50

Pain or burning white urination

50

50

50

50

Pain during sexual intercourse

50

50

50

50

Abnormal vaginal discharge

50

50

50

50

Swelling

50

50

50

50

Vulvar redness

50

50

50

50

 

Table after 7 days

Symptoms

Group 1

Improvement in symptoms out of 50 patients

Group 2

Improvement in symptoms out of 50 patients

Group 3

Improvement in symptoms out of 50 patients

Group 4

Improvement in symptoms out of 50 patients

Itching or soreness in vagina

32

28

18

34

Pain or burning white urination

28

26

28

32

Pain during sexual intercourse

16

12

20

28

Abnormal vaginal discharge

22

15

6

25

Swelling

10

11

11

14

Vulvar redness

6

8

5

19

 

Table after 14 days

Symptoms

Group 1

Improvement in symptoms out of 50 patients

Group 2

Improvement in symptoms out of 50 patients

Group 3

Improvement in symptoms out of 50 patients

Group 4

Improvement in symptoms out of 50 patients

Itching or soreness in vagina

40

41

36

45

Pain or burning white urination

33

28

25

42

Pain during sexual intercourse

38

32

26

34

Abnormal vaginal discharge

44

33

23

40

Swelling

25

39

26

38

Vulvar redness

26

29

20

24

 

DISCUSSION

This study aimed to evaluate the age distribution and symptom improvement in patients with vulvovaginal candidiasis, focusing on the progression of symptoms over a 14-day period. A total of 200 patients participated, and their data was analysed across different age groups and treatment groups.

 

The age distribution (Table 1) reveals that the majority of patients with vulvovaginal candidiasis fall within the 26-33 years age group (47.5%), followed by the 18-25 years group (23%). The remaining patients were in the 34-41 years (16%) and 42-50 years (13.5%) categories. This suggests that vulvovaginal candidiasis is most common among women in their late twenties to early thirties. This age group often experiences higher levels of reproductive health activity, which may contribute to the increased prevalence of this condition.

 

Symptoms of vulvovaginal candidiasis were consistent across all four groups (Group A, B, C, and D), with all patients reporting common symptoms such as itching, pain during urination, pain during sexual intercourse, abnormal vaginal discharge, swelling, and vulvar redness. These findings (Table 2) indicate that the disease manifests similarly across different populations of patients, and that a standardized symptom assessment can be used for diagnosing and managing the condition in clinical settings.

After 7 days of treatment, some improvement in symptoms was observed across all four groups (Table 3). Group 1 showed the highest improvement in symptoms related to itching or soreness in the vagina (32 out of 50 patients), pain or burning during urination (28 patients), and pain during sexual intercourse (16 patients). Group 4 demonstrated significant improvement in most symptoms, particularly in itching or soreness in the vagina (34 patients) and pain or burning during urination (32 patients). Notably, Group 4 showed better overall symptom improvement, especially in vulvar redness, where 19 patients out of 50 experienced symptom relief after 7 days.

 

After 14 days of treatment (Table 4), improvements in symptoms were more pronounced across all groups. Group 4 continued to show the most substantial improvements, particularly in itching or soreness in the vagina (45 out of 50 patients), pain during sexual intercourse (34 patients), and abnormal vaginal discharge (40 patients). Group 2 also showed significant improvement, particularly in vulvar redness (29 patients). These results suggest that a longer treatment duration may be associated with better symptom resolution, particularly for Group 4, which could indicate the effectiveness of the specific treatment regimen used in that group.

 

When comparing the groups, it is clear that Group 4 exhibited the most consistent and significant improvement in symptoms, especially after the 14-day mark. While all groups showed some level of improvement, the variation in response rates across the groups suggests that treatment regimens or underlying patient characteristics may play a role in the overall outcome. The differences in symptom improvement may be attributed to the differing interventions or therapies provided to each group.

 

Qin F et al. (2018) [16] conducted a meta-analysis including 41 randomized controlled trials. They analyzed the relative risk of vulvovaginal candidiasis (VVC) associated with ten drugs, including a placebo, fluconazole, clotrimazole, miconazole, itraconazole, ketoconazole, econazole, butoconazole, terbinafine, and terconazole. The following drugs demonstrated greater efficacy than placebo in treating patients: fluconazole (OR = 6.45, 95% CrI 4.42–9.41), clotrimazole (OR = 2.99, 95% CrI 1.61–5.55), miconazole (OR = 5.96, 95% CrI 3.17–11.2), itraconazole (OR = 2.29, 95% CrI 1.21–4.33), ketoconazole (OR = 2.40, 95% CrI 1.55–3.71), butoconazole (OR = 1.18, 95% CrI 1.06–1.31), and terconazole (OR = 5.60, 95% CrI 2.78–11.3). The surface under the cumulative ranking curve (SUCRA) for each drug was as follows: placebo (0.5%), fluconazole (91.5%), clotrimazole (61.8%), miconazole (33.8%), itraconazole (50.5%), ketoconazole (42.8%), econazole (46.8%), butoconazole (82.2%), terbinafine (20.9%), and terconazole (65.0%). Based on this analysis, antifungal drugs were found to be effective in treating VVC, with fluconazole showing the highest efficacy.

 

Mikamo H et al. (1988) [17] found that, at both short-term and long-term assessments, Candida species were completely eradicated from the vagina in 80% and 74% of patients, respectively, in the 3-day oral itraconazole group; 76% and 70% in the single oral fluconazole group; and 72% and 60% in the intravaginal clotrimazole group. The clinical effectiveness rates were 92% and 88% in the 3-day oral itraconazole group, 80% and 76% in the single oral fluconazole group, and 72% and 58% in the intravaginal clotrimazole group, respectively. No treatment-related side effects were reported in any of the groups. The study suggests that both oral itraconazole and oral fluconazole are effective treatments for vaginal candidiasis, with these therapies offering viable options for managing the condition.

CONCLUSION

This study underscores the common occurrence of vulvovaginal candidiasis among women aged 26-33 and highlights the typical symptoms associated with the condition. While all treatment groups showed improvement over the 14-day period, Group 4 displayed the most pronounced recovery, especially for symptoms like vaginal itching, urinary burning, and abnormal discharge. This suggests that longer treatment regimens or different therapeutic approaches may offer better symptom resolution. Further studies could explore the underlying reasons for the variations in symptom improvement and aim to optimize treatment strategies for this common condition.

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