What is the recommended treatment for cytolytic vaginosis and vulvovaginal candidiasis?

Treatment Recommendations for Cytolytic Vaginosis and Vulvovaginal Candidiasis

For cytolytic vaginosis, sodium bicarbonate (baking soda) sitz baths are the recommended treatment, while vulvovaginal candidiasis should be treated with either topical azole medications or oral fluconazole depending on severity and patient factors. 1, 2

Diagnosis and Differentiation

Vulvovaginal Candidiasis (VVC)

• Characterized by pruritus, vaginal discharge, soreness, vulvar burning, dyspareunia, and external dysuria 2
• Diagnosis confirmed by:
  • Wet preparation (saline, 10% KOH) or Gram stain showing yeasts or pseudohyphae
  • Positive culture for yeast species
  • Normal vaginal pH (<4.5) 2
• Approximately 75% of women will experience at least one episode of VVC in their lifetime 2

Cytolytic Vaginosis (CV)

• Often misdiagnosed as VVC due to similar symptoms 1, 3
• Diagnostic criteria include:
  • Vaginal pH ≤4.5
  • Presence of large numbers of lactobacilli
  • Cytolysis of vaginal epithelial cells
  • Absence or minimal presence of neutrophils
  • Absence of other pathogens 1, 4
• Symptoms often follow a cyclic pattern with worsening during luteal phase 3

Treatment Recommendations

For Vulvovaginal Candidiasis

Uncomplicated VVC:

• Oral treatment:

  • Fluconazole 150 mg oral tablet, single dose 2, 5

• Topical treatments (equally effective alternatives):

  • Clotrimazole 1% cream 5g intravaginally for 7-14 days
  • Clotrimazole 100 mg vaginal tablet for 7 days
  • Clotrimazole 100 mg vaginal tablet, two tablets for 3 days
  • Clotrimazole 500 mg vaginal tablet, single application
  • Miconazole 2% cream 5g intravaginally for 7 days
  • Miconazole 200 mg vaginal suppository, one suppository for 3 days
  • Miconazole 100 mg vaginal suppository, one suppository for 7 days
  • Terconazole 0.4% cream 5g intravaginally for 7 days
  • Terconazole 0.8% cream 5g intravaginally for 3 days
  • Terconazole 80 mg vaginal suppository, one suppository for 3 days 2

Complicated VVC (severe, recurrent, or non-albicans species):

• Longer duration of therapy (7-14 days) with topical agents or fluconazole 150 mg every 72 hours for 3 doses 2
• For recurrent VVC (≥4 episodes per year):
  • Initial intensive therapy for 10-14 days
  • Followed by maintenance therapy with weekly fluconazole 150 mg for 6 months 2

For Cytolytic Vaginosis:

• Primary treatment: Sodium bicarbonate (baking soda) sitz baths 1, 3
  • Standardized NaHCO₃ sitz baths have shown significant improvement in symptoms with complete resolution in over 80% of patients 1
• Additional measures:
  • Discontinue all antifungal agents
  • Use pads instead of tampons during menstruation
  • Baking soda douches may also be helpful 3
• Rationale: Treatment aims to increase vaginal pH to counteract the overgrowth of lactobacilli 1, 4

PARQ Discussion Points

For Vulvovaginal Candidiasis:

Purpose:

• Explain that treatment aims to eliminate the Candida infection causing symptoms 2
• Discuss that both topical and oral medications work by disrupting the fungal cell membrane 5

Alternatives:

• Present options between oral fluconazole (single dose) versus topical treatments (varying durations) 2
• Discuss that topical and oral treatments have equivalent efficacy (80-90% cure rates) 2

Risks:

• Oral fluconazole: Possible side effects include headache (13%), nausea (7%), abdominal pain (6%), and diarrhea (3%) 5
• Topical agents: May cause local burning or irritation; oil-based creams and suppositories may weaken latex condoms 2
• Rare but serious: Hepatotoxicity with oral agents (especially with multiple doses) 5

Questions to address:

• Duration of treatment and when to expect symptom improvement
• Need for follow-up (only if symptoms persist)
• Partner treatment (generally not necessary unless partner is symptomatic) 2

For Cytolytic Vaginosis:

Purpose:

• Explain that CV is caused by an overgrowth of normal vaginal lactobacilli, not an infection 1, 4
• Treatment aims to normalize vaginal pH and restore balance to the vaginal microbiota 1

Alternatives:

• Sodium bicarbonate sitz baths are the primary treatment 1, 3
• No antimicrobial treatments are indicated as this is not an infection 4

Risks:

• Minimal risks with baking soda sitz baths
• Main risk is continued discomfort if misdiagnosed as VVC and treated with antifungals 3

Questions to address:

• Explain the cyclic nature of symptoms and potential for recurrence
• Emphasize importance of avoiding unnecessary antifungal treatments
• Discuss preventive measures for future episodes 3, 6

Important Clinical Considerations

• Accurate diagnosis is crucial as CV is often misdiagnosed as VVC, leading to inappropriate antifungal treatment 1, 3
• The diagnostic sensitivity and specificity of epithelial cytolysis for CV is 80% and 99%, respectively 4
• Self-medication with OTC antifungals should only be recommended for women previously diagnosed with VVC who experience recurrence of the same symptoms 2
• Women whose symptoms persist after using OTC preparations or who experience recurrence within 2 months should seek medical care 2
• For pregnant women with VVC, only topical azole therapies should be used 2