Vulvovaginal candidiasis. Vulvovaginal candidiasis and its treatment. Treatment of vulvovaginal candidiasis in young children

Vulvovaginal candidiasis is a common, often infectious disease found in women. different ages. This disease is most often diagnosed in young girls and women of childbearing age. Otherwise, this disease may be called thrush, vuvolvaginal mycosis, or genital fungus. This pathology is very widespread, diagnosed in approximately 45% of women. Difficulties in treatment arise due to the fact that this disease is prone to relapses and chronicity. This picture emerges due to the root cause of thrush. The causative agents of the disease are yeast-like pathogenic fungi that are constantly present in different quantities in organism. There are more than 100 different types of them, so it is important to competently approach the selection of medicine in order to have an effect. In normal times, Candida fungi do not show aggressiveness or excessive activity and are suppressed by beneficial microflora. But if favorable conditions are created, colonies of the fungus begin to rapidly grow, affecting the surfaces of the mucous membranes, internal organs, skin. The disease, left without treatment, can quickly become severe and chronic, leading to a lot of unpleasant consequences.

Symptoms of different forms of fungal disease

Candidiasis under a microscope

There are three main forms of vulvovaginal candidiasis. The mild form begins abruptly, the basic symptoms are very pronounced, but under the influence of medications the disease disappears quite quickly. The acute form of thrush occurs when the infection does not respond to treatment. Some may be added additional symptoms. The chronic form of genital fungus is diagnosed in cases where the disease constantly returns (more than four times in one year), its symptoms are significantly pronounced, and therapy does not give a full result. A similar picture is observed in approximately 5% of all patients with candidal pathology.

Typical symptoms

Foci of infection are recorded in the intimate area. The mucous membranes, vagina, vulva, and organs of the genitourinary system are affected. The symptoms differ in that they are pronounced and increase as the disease progresses. In rare cases, the disease may have a so-called latent form, when external signs is not visible, and the diagnosis is made to the patient by chance after a routine examination.

The following symptoms may accompany candidiasis of the vulva and vagina:

As a rule, signs of fungal pathology are especially noticeable before or after menstruation, as well as during pregnancy. They intensify in the evening and at night, after taking a warm shower or bath. The condition worsens after intimacy, prolonged walking or after playing sports.

What provokes the development of a painful condition

The root cause of thrush is fungi that exhibit aggressive activity. This can be provoked by a variety of external and internal factors. Despite the fact that men do not often experience obvious manifestations of candidiasis, they can act as carriers of active fungi. After unprotected sexual intercourse, infection occurs, and then the woman is faced with the development of the disease in herself. You can also become infected through personal hygiene items. During pregnancy, if the pathology is not treated in any way, the condition is not corrected, there is a risk of infection of the newborn.

Common Causes

Regular and severe stress, depression, poor diet and fasting, and lack of vitamins and mineral trace elements in the body can increase the risk of developing fungal pathology.

Risks and complications

If symptoms and general condition are ignored for a long time, the risks of complications increase. In this case, there is not only a threat of candidiasis becoming chronic and sluggish, which will constantly accompany the woman.

The main complications are:

Treatment Options

The treatment plan is developed individually. Treatment is based on diagnostic results, which includes examination and questioning of the patient, procedures and necessary tests. When selecting medications and methods of therapy, complaints, the presence of additional diseases and possible allergic reactions, and general health are taken into account. An important role is played by data on female microflora and which subspecies of harmful yeast-like fungi is active. When a candidiasis-type disease occurs in pregnant women, only a professional doctor can decide exactly what correction methods to use. Due to all such nuances, carry out self-treatment and the choice of anti-thrush remedies should not be followed. Otherwise, the situation can only be aggravated without obtaining any positive effect.

Medicines

Vulvovaginitis is treated with antifungal drugs (for example, Nystatin), imidazole agents (Bifonazole, Fluconazole, Lamisil), and various medications local use(Decamine, Betadine). Iodine preparations and combination drugs (for example, Pimafucort) can be used.

Mikospor cream containing Bifonazole

The following medications are especially often prescribed to patients:

• Itraconazole
• Butoconazole.
• Miconazole and others.

Non-drug correction options

Along with medications, traditional medicine can also be used. It is based on the selection of the most effective gynecological preparations, medicinal flowers, etc. Using soda solutions may be helpful.

Traditional medicine serves as so-called supportive therapy. With the help of decoctions and infusions, washing is carried out, compresses, lotions, gauze swabs, and douching are made. However, the use of such drugs should be carried out exclusively as prescribed by a medical specialist. It is important to carefully monitor your health to avoid an unpleasant allergic reaction to herbs.

Herbs - effective remedy from candidiasis

The effectiveness of treatment will depend not only solely on the correct selection of the necessary funds. Life correction and treatment are important concomitant diseases, accurate identification of the causes provoking outbreaks of fungal pathology.

1. change your diet, removing sweet and carbohydrate foods from the menu as much as possible;
2. refrain from taking antibiotics and other potent drugs, especially those that suppress the activity of the immune system;
3. strengthen the immune system through hardening, water procedures, sports, active additives and vitamins;
4. refuse sexual intercourse during treatment, and unprotected sex at other times;
5. eliminate alcohol consumption, get rid of bad habits;
6. minimize stress in life, improve your daily routine;
7. stop taking oral contraceptives containing estrogen;
8. change your wardrobe, give up synthetic underwear;
9. improve daily intimate hygiene, refrain from using untested means;
10. promptly treat any diseases, inflammatory processes, support general health fine;
11. avoid overheating and hypothermia, any negative impacts on the immune system.

It will also be important to implement preventive measures that will prevent relapses of this fungal pathology. These build on the additional tips above. In addition, after consulting with your doctor, you can take preventive medications from time to time.

14.04.2017

Vulvovaginal candidiasis (VVC) is an infectious urogenital disease that affects the mucous membrane of the vagina, vulva, perineum, and urethra.

The inflammatory process is caused by Candida fungi. In terms of frequency of cases, the manifestation of VVC is in 2nd place after bacterial vaginosis.

More than half of the women on the planet have experienced signs of vulvovaginal candidiasis once in their lives. To reduce the likelihood of illness, you need to take antibiotics only as prescribed by a doctor, support your immune system, adjust your diet, choose the right means contraception, maintain personal hygiene.

In medicine, there are 2 forms of the disease with vulvovaginal candidiasis - acute and chronic. The causative agent of the disease is often fungi of the Candida family (C. albicans, C. krusei, C. pseudotropicalis, C. parapsilosis C. glabrata), but in Lately The number of diseases caused by fungi Saccharomyces cerevisae, Torulopsis glabrata, etc. is growing.

Causes of vulvovaginal candidiasis

Normally, yeast-like fungi are present in the microflora of every person. With accompanying factors, fungi actively multiply, and thrush begins.

The main reasons contributing to increased fungal activity:

• pregnancy, diabetes;
• incorrectly chosen underwear (synthetic, tight);
• long-term use of antibiotics, steroids, oral contraceptives;
• abuse of wearing pads;
• neglect of hygiene or excessive cleanliness.

Symptoms of VVC

A doctor should diagnose vulvovaginal candidiasis, but a woman can independently assume the presence of the disease if she notices a symptom characteristic of thrush from the following:

• severe burning, itching of the genitals, deterioration after sexual intercourse, water procedures, during menstruation, during a long walk;
• discharge with a cheesy consistency gray-white color;
• swelling and hyperemia of the genital mucosa, bleeding wounds.

If you notice several symptoms, you need to consult a doctor. If vulvovaginal candidiasis is not treated in time, it can lead to infections in the pelvic organs and urinary system, vaginal stenosis, premature birth, low birth weight babies, etc.

Diagnostic tests

To choose the right treatment, the doctor must make sure that the patient has vulvovaginal candidiasis, or identify another disease that has similar symptoms (discharge, itching, damage to the mucous membrane, etc.).

The doctor will rely on the results of a physical examination, the patient’s complaints, and laboratory test data. The laboratory carries out microbiological and immunofluorescent diagnostics, serological and immunological studies. As a rule, mycosis is not sexually transmitted, but if a man is diagnosed with candidal balanoposthitis, both partners are treated.

Treatment of vulvovaginal candidiasis

Treatment of VVC in acute form usually does not cause difficulties. The doctor prescribes suitable antifungicidal drugs from the azole group; during treatment, you need to avoid antibiotics, glucocorticoids, and hormones.

For successful treatment bad habits need to be eliminated, the diet adjusted, and a comprehensive effect on areas affected by the fungus. In addition to medicinal drugs, recommendations are given on hygiene and the choice of underwear. Traditional recipes can be used as aids for the treatment of candidiasis. These can be decoctions, compresses, baths, douching with solutions of medicinal herbs. The dosage and duration are determined by the doctor.

If the disease occurs in chronic form with regular relapses, treatment will be difficult. The patient will be prescribed antifungal drugs and auxiliary therapy. The doctor chooses a local remedy based on test results, the patient’s age, and concomitant diseases.

The choice of medications must be made from the following drugs:

• butoconazole cream 2% is administered once into the vagina in an amount of 5 mg;
• ketoconazole suppositories 400 mg are prescribed for 3-5 days;
• fluconazole tablets – 150 mg 1 time;
• Itraconazole 200 mg tablets are taken twice a day, course – 3 days;
• vaginal suppository sertaconazole 300 mg – once;
• clotrimazole in different forms (vaginal tablets of 100 m are prescribed for a week, tablets of 200 mg are prescribed for 3 days, a tablet of 500 mg is prescribed once, and a 1% cream is administered into the vagina for a week or two);
• miconazole suppositories are prescribed at 100 mg per week or 200 mg for 3 days;
• Nystatin suppositories are prescribed for 2 weeks of daily use;
• Tioconazole ointment 6.5% is applied intravaginally once.

Despite the high effectiveness of local antifungal drugs, in many patients vulvovaginal candidiasis reappears after 3 months.

The cause of relapse may be antibiotics, which, with prolonged use, can change the vaginal microflora. Also, the risk of developing VVC again is greater in those patients who use hormonal contraceptives or are pregnant.

An increase in estrogen levels entails an increase in glycogen, which creates favorable conditions for the proliferation of fungi. For the same reason, women with diabetes often suffer from vaginal candidiasis - against its background, immunity decreases, glycogen increases.

Another factor due to which thrush recurs is an increase in the types of fungi, causing diseases. Thus, the varieties C. glabrata, C. pseudotropicalis, C. parapsilosis are less sensitive to traditional therapy than C. albicans. The difficulty of choosing a drug is explained by neglect of the recommended treatment regimen. If the patient completes the course of therapy before complete cure has occurred, the fungi recur and become resistant to certain medications.

It is important to consider that if in the acute form of the disease local antifungal agents may be sufficient, then chronic vulvovaginal candidiasis is treated comprehensively - a combination of local, systemic and anti-relapse drugs. Additionally, immunomodulatory agents are prescribed, as well as those aimed at normalizing the microflora.

To treat the chronic form of thrush, local drugs from the azole group are prescribed for about 2 weeks. In parallel, patients are prescribed a systemic antifungal drug (itraconazole tablets twice a day, 200 mg for 3 days, fluconazole tablets once a day, 150 mg for 3 days, etc.).

Prevention of candidiasis

To prevent relapses of vulvovaginal candidiasis, the doctor may prescribe itraconazole 200 mg tablets, fluconazole 150 mg and other drugs listed below. You will need to take 1 tablet on the 1st day of menstruation. Repeat for six months. Additional assistance will be provided by local medications, which are used once a week for the same period.

Popular antifungal tablets include the following:

• levorin 500 thousand units. Taken as prescribed by a doctor up to 4 times a day, course 10-12 days;
• nystatin 500 thousand units. It is taken according to the doctor’s recommended regimen up to 5 times a day, the duration of therapy is 10-14 days. To increase the effectiveness of the drug, intravaginal nystatin suppositories are used in parallel;
• amphoglucamine 200 thousand units. Taken twice a day, course 10-14 days.

Among the effective local drugs are:

• drugs from the group of imidazoles (clotrimazole, ginesol, miconazole, bifonazole, isoconazole, ginalgin) - 1 suppository or 1 dose of cream inside the vagina before bed, course - 10 days;
• polygynax (polymyxin, neomycin, nystatin) 1 suppository in the vagina at night, course duration - 12 days;
• terzhinan (neomycin, ternidazole, nystatin) – 1 suppository at night, course – 10 days;
• pimafucort (neomycin, amycin, hydrocortisone) – ointment or cream is inserted into the vagina 2-4 times a day, course – 2 weeks;
• betadine – 1 suppository at night, the course lasts up to 2 weeks;
• meratin-combi (neomycin, ornidazole, nystatin) - 1 suppository intravaginally at night, duration of therapy - 10 days.

An important condition for successful treatment of thrush is completing the course of therapy only after the doctor is convinced that the causative agent of the disease has been defeated. During treatment acute form candidiasis, a week after the end of the prescribed course of therapy, the patient’s health condition is monitored.

When assessing the effectiveness of treatment for chronic candidiasis, you need to monitor your health for 3 months in a row, consulting a doctor on the 1st day after menstruation.

The doctor will take a smear from the vagina to examine the discharge under a microscope and order a culture to determine pathogenic microorganisms and their sensitivity to drugs.

Thrush in women or vulvovaginal candidiasis is one of the most common reasons for seeking help from an antenatal clinic. This frequent occurrence is due to the widespread occurrence of the pathogen in the environment.

The causative agent of vulvovaginal candidiasis is a fungus of the genus Candida. This opportunistic microorganism has an oval or round shape. Unlike other fungi, they do not form true mycelium; their pseudomycelium is formed due to the elongation of their own cells, which, adjacent to each other, form chains.

The most favorable conditions for their reproduction are acidic environment and temperature from 21 to 37 degrees. Several representatives of the genus are of clinical importance - C. albicans, C. glabrata, C. tropicalis, C. krusei, C. parapsilosis.

Up to 70% of all cases are associated with C. albicans, however, recently the proportion of other pathogens has been increasing. Candida resistance to available antifungal drugs is also increasing.

The issue of sexual transmission of candidiasis is still controversial. How is it transmitted? Should I treat my sexual partner? The questions are relevant, everyone has their own answers.

The fact is that in the medical literature there is information that in men whose partners are being treated for VVC, the pathogen is detected only in 50% of cases.

The remaining 50% are either completely healthy or have another type of fungus.

Therefore, you should know that if a woman has a laboratory-confirmed episode of thrush, her sexual partner also needs to undergo smears and, if a pathogen is detected, undergo treatment.

Treatment is definitely required for men with clinical manifestations - inflammation of the glans penis, itching, swelling, cheesy deposits.

The sexual partner, of course, can be blamed for being the source of infection. However, this would not be correct. Almost 80% of people first encounter candida in the maternity hospital, receiving it from their mother, while passing through birth canal, or simply from the environment. The fungus settles on the skin and mucous membranes and can exist there peacefully all its life without causing any problems to the owner.

The causes of thrush in women are the most commonplace - decreased immunity.

Why is thrush dangerous?

Vulvovaginal candidiasis in women most often manifests itself only in damage to the genitourinary system. There is no danger to life. Problems can be expected in several cases:

• absence adequate treatment, while large areas are involved in the process, including skin, which means he becomes a woman’s companion for life;
• a very strong decrease in immunity and the spread of the infectious process through the lymphatic and blood vessels to other organs and tissues, generalization of the process, sepsis (occurs extremely rarely in very weakened patients);
• vulvovaginal candidiasis during pregnancy is dangerous due to the possibility of the process spreading from the vagina to the uterus, to the fetus (fortunately, this is also rare);
• Thrush during lactation can spread to the nipples, and there is also a high risk of injury to the baby.

For convenience, we will try to divide the causes of thrush in women into several groups.

External, or exogenous causes include:

1. Effect of drugs on immunity. When taking hormonal drugs, as well as cytostatics, the immune system is suppressed and the body's ability to adequately respond to an infectious threat is reduced.
2. A woman taking combined oral contraceptives. Previously, it was believed that thrush was provoked by those OCs that contain high doses of estrogens. However, in practice, everything depends on the patient’s body - any of the hormonal contraceptives available on the market can lead to the development of candidiasis.
3. Acute infectious diseases, especially those that require antibiotics. Antibiotics suppress growth and reproduction not only pathogenic microbes, but also normal flora, without affecting fungi and viruses in any way, and in the absence of competition, candida begins to multiply intensively.
4. Injuries and microtraumas of the vaginal mucosa under the influence of chemical, inflammatory, mechanical factors. If we specify this point, it can be endless - the mucous membrane is injured during sexual intercourse, when washing with soap and other surfactants, when using spermicides, when STIs enter the body, etc.

Another group of factors contributing to the development of thrush are internal:

• diseases of endocrine organs: , diseases thyroid gland with hormonal dysfunction, menstrual cycle disorders.
• nutritional factors– insufficient intake of vitamins and microelements from food (anemia, hypo- and avitaminosis).
• diseases and functional disorders gastrointestinal tract.
• pregnancy.

The signs of thrush are quite widely known. The classic course implies the presence of itching, burning, swelling, cheesy discharge, and pain.

Itching, burning and swelling appear under the influence of mediators (biologically active compounds) of inflammation, which, acting on receptors, lead to an increase in blood supply to the affected tissues and their irritation. Itching and burning intensify in the evening, after a long stay on your feet.

The culprits of pain are the same inflammatory mediators. The pain intensifies after urination, after sexual intercourse. Sometimes it becomes so intense that a woman refuses sexual activity altogether, which can disrupt her relationship with her partner.

The discharge is most often abundant, yellow in color, cheesy, and has a creamy consistency. Sometimes the discharge is liquid, interspersed with “cottage cheese”, and has an unpleasant odor.

If the lesion spreads to the skin, complaints such as redness, swelling, pinpoint rash, maceration of the skin, itching in the perineum and anus appear.

The chronic form of candidiasis is characterized by a process duration of more than 2 months, the main familiar symptoms fade into the background, tissue atrophy and infiltration predominate.

Up to 10% of women may suffer from recurrent vulvovaginal candidiasis. At the same time, clinically pronounced and laboratory-confirmed episodes of thrush are recorded 4 or more times a year.

The most accessible method for diagnosing candidiasis is a microscopic examination of a smear. The sampling is carried out by a specialist using a cytobrush or a Volkmann spoon, after which the material is applied to a glass slide, dried, fixed and stained in the laboratory and examined under a microscope.

In an acute process, clusters of yeast cells are found in smears; in a chronic process, clusters of pseudomycelium are found.

Currently, the method of express diagnosis of candidiasis is widespread - ready-made test systems are sold in pharmacies and allow you to confirm or refute the diagnosis in a short time, even at home.

Another fairly accessible, but at the same time troublesome, method is cultural or “seeding”.

Given the difficulties in storing and delivering material, long time waiting for the result, the need for a special laboratory, it is resorted to in case of difficulty in making a diagnosis and to obtain the sensitivity of the pathogen to antifungal drugs when standard treatment regimens are ineffective.

PCR diagnostics can also be used to detect a fungus, however, the method is relatively expensive, and very often the question of overdiagnosis arises - the pathogen can be detected in completely healthy women who do not require treatment (the method allows you to complete a DNA chain from a small fragment of a cell).

The treatment of thrush should be carried out by a specialist, it should be comprehensive, in compliance with the rules for taking medications.

Self-medication without confirming the diagnosis can result in chronicity inflammatory process. Under the mask of thrush, other diseases may be hiding, the treatment of which with antifungal drugs will not have any effect.

Once the diagnosis of vulvovaginal candidiasis is laboratory confirmed, a treatment regimen is selected. In case of an acute episode, preference should be given to local forms - suppositories, vaginal tablets, creams. Although oral medications have proven their effectiveness, they have a systemic effect, i.e. act on other organs and tissues.

Local medications are divided into azole derivatives and antifungal antibiotics. The first group includes clotrimazole, miconazole, econazole, butoconazole, isoconazole, and ketoconazole. The second includes nystatin and natamycin. Regardless of which drug was prescribed, there is one requirement - a full course of treatment.

The average course of local antifungal agents is 6-7 days, but there are both drugs that require longer use - nystatin, and drugs whose course is limited to a single administration - isoconazole, butoconazole.

The price of antifungal drugs largely depends on the reputation of the manufacturer. In the article we indicated international common names so as not to single out anyone and not to offend anyone.

Of the antifungal drugs for oral administration, azole derivatives - fluconazole and itraconazole - can be prescribed for the treatment of vulvovaginal candidiasis; they are convenient with a short treatment regimen, affordable (the cost again depends on the manufacturer), but are contraindicated in pregnant and lactating women. Itraconazole is also contraindicated in children.

In addition to antifungal drugs, after the main treatment, agents can be prescribed to restore the vaginal biocenosis and stimulate the immune system. Proper nutrition and intimate hygiene are important.

Widespread and, oddly enough, quite effective. Let’s immediately say, of course, that traditional methods of treatment are good in combination with standard antifungal therapy. They help alleviate the condition and speed up recovery. As monotherapy, traditional methods of treatment are not always effective.

Most often, the vulva and vagina using soda solution. To do this, you need to dilute a tablespoon of soda in a liter of warm water, stir well and wash yourself 2 times a day, immediately before inserting a suppository into the vagina.

Soda is also used for douching; douching is performed with an enema with a soft spout until the discharge is completely washed out. To increase the effectiveness of the procedure, you can add a teaspoon of iodine to the soda.

Among folk methods, infusions of plant materials - chamomile, calendula, oak bark, birch buds, etc. - have also proven effective. To prepare the infusion, you need to pour 2 tablespoons of dry raw materials with 1 liter of boiling water. Leave for thirty minutes in a thermos, cool and use as directed twice a day.

For women, preference should be given to douching or washing; for little girls, preference should be given to sitz baths. Baths are effective for lesions of the labia and vulva.

The duration of the procedure is no more than 5 minutes, twice a day for 7-10 days. Each time the solution is prepared fresh, before immersion, you should wash the anal area with warm water and soap.

Douching is contraindicated for pregnant women and in the first months after childbirth, because the infection can flow through the cervical canal into the uterine cavity and spread to its membranes, causing endometritis and infection of the fetus.

Vulvovaginal candidiasis during pregnancy. How to treat?

For the treatment of uncomplicated forms of thrush during pregnancy, preference is given to vaginal forms of antifungal drugs. They are practically not absorbed from the vagina, do not have systemic effects and do not have harmful influence for the fruit.

From the first trimester, natamycin is allowed, from the second the list expands significantly - clotrimazole, miconazole, butoconazole. Among complex drugs, they are widely used vaginal tablets terzhinan.

Antifungal drugs for oral administration during pregnancy are prescribed only if the infection becomes generalized and can threaten the woman’s life.

Prevention of thrush in women

To prevent thrush, a woman must follow the rules of personal hygiene, avoid casual sex, monitor her health and eat right.

It is recommended to limit use detergents When caring for the genitals, avoid synthetic underwear and tight clothing, and minimize the use of panty liners and lubricants.

You definitely need to include fiber in your diet. dairy products, enrich it sufficient quantity vegetables and fruits, it is recommended to exclude fast food, fatty, spicy foods, limit sweets and flour, and alcohol.

The incidence of vulvovaginal candidiasis has shown a clear upward trend over the past 20 years. Currently, vulvovaginal candidiasis ranks second in prevalence after bacterial vaginosis. From 15 to 40% of infectious lesions of the vulva and vagina are caused by a fungal infection. About 75% of women suffer from this disease at least once in a lifetime. From 40 to 50% of women have relapses of vulvovaginitis, and in 5–8% the disease becomes chronic. The article presents modern data on the etiology, pathogenesis, epidemiology, and classification of this pathology. Approaches to the diagnosis and clinical picture of vulvovaginal candidiasis are reflected. The presence of a combined form of vulvovaginal candidiasis and bacterial vaginosis was identified. In treatment, special attention is paid to the use of the drug clotrimazole as an imidazole derivative in the treatment of vulvovaginal candidiasis. It has been noted that clotrimazole is effective against dermatophytes, yeast-like fungi, molds and protozoa. Clotrimazole has an antimicrobial effect against gram-positive (Streptococcus spp., Staphylococcus spp.) and anaerobic bacteria (Bacteroides spp., Gardnerella vaginalis), which makes it possible to use it in the combination of vulvovaginal candidiasis with concomitant disorders of the vaginal microbiota.

Keywords: vulvovaginal candidiasis, bacterial vaginosis, trichomoniasis, differential diagnosis, antimycotics, clotrimazole.

For quotation: Pestrikova T.Yu., Yurasova E.A., Kotelnikova A.V. Vulvovaginal candidiasis: modern look to the problem // RMJ. Mother and child. 2017. No. 26. S. 1965-1970

Vulvovaginal candidiasis: modern look at the problem
Pestrikova T.Yu., Yurasova E.A., Kotelnikova A.V.
Far Eastern Medical State University, Khabarovsk

The incidence rate of candidal vulvovaginitis has a clear tendency to increase over the past 20 years. Currently, the vulvovaginal candidiasis is on the second place after bacterial vaginosis by the prevalence rate. From 15 to 40% of infectious lesions of the vulva and vagina are caused by a fungal infection. About 75% of women suffer from this disease at least once during their lifetime. From 40% to 50% of women have recurrences of vulvovaginitis, and in 5-8% of women the disease becomes chronic. The article presents modern data on etiology, pathogenesis, epidemiology, classification of this pathology, and reflects approaches to diagnostics and clinical picture of candidiasis vulvovaginitis. The presence of a combined form of candidal vulvovaginitis and bacterial vaginosis is highlighted. In the treatment, special attention is paid to the use of the drug clotrimazole, as an imidazole derivative, in the treatment of vulvovaginal candidiasis. It was noted that clotrimazole is effective against dermatophytes, yeast, molds and protozoa. Clotrimazole has an antimicrobial effect against gram-positive bacteria (Streptococcus spp., Staphylococcus spp.) and anaerobes (Bacteroides spp., Gardnerella vaginalis), which makes it possible to use clotrimazole in vulvovaginal candidiasis combined with concomitant vaginal microbiota disorders.

Key words: vulvovaginal candidiasis, bacterial vaginosis, trichomoniasis, differential diagnosis, antimycotics, clotrimazole.
For citation: Pestrikova T.Yu., Yurasova E.A., Kotelnikova A.V. Vulvovaginal candidiasis: modern look at the problem // RMJ. 2017. No. 26. P. 1965–1970.

The article presents modern data on the etiology, pathogenesis, epidemiology, classification of vulvovaginal candidiasis. In treatment, special attention is paid to the use of the drug clotrimazole as an imidazole derivative in the treatment of vulvovaginal candidiasis.

Introduction

Vulvovaginal candidiasis (VVC) is an infectious lesion accompanied by inflammation of the vaginal mucosa, which is caused by fungi of the genus Candida. This disease is notable because normally fungi Candida live in the intestines of women and do not cause harm to health. But under certain conditions, mushrooms Candida albicans can replace the normal microflora of a woman’s vagina and cause candidal vaginitis/vulvitis.

Codes according to the International Classification of Diseases, 10th revision:

B37. Candidiasis.
B37.3. Candidiasis of the vulva and vagina.
B37.4. Candidiasis of other urogenital localizations.
B37.9. Candidiasis, unspecified.

Epidemiology

The incidence of VVC has shown a clear upward trend over the past 20 years. Currently, VVC ranks second in prevalence after bacterial vaginosis. A number of authors indicate that VVC is one of the most common reasons for patients to visit a gynecologist. According to various researchers, from 15 to 40% of infectious lesions of the vulva and vagina are caused by fungal infections. About 75% of women suffer from this disease at least once during their lifetime. 40–45% of patients experience two (or more) episodes of VVC throughout their lives. 10–20% of women are asymptomatic carriers of fungi, and fungi are most often localized in the vagina; In pregnant women, fungal colonization can reach 40%.
The prevalence of recurrent forms of candidiasis in the world is about 3 million cases per year. From 40% to 50% of women have relapses of vulvovaginitis, and in 5–8% the disease becomes chronic. The incidence of VVC will continue to increase due to the increase in infection Candida non-albicans(resistant to most antifungal drugs), as well as due to the development of resistance to antifungal drugs.
The prevalence of VVC varies among different age groups. Studies have shown that VVC most often affects women aged 21 to 40 years, i.e., the most able-bodied part of society, which once again indicates the high social significance of this problem. In girls before menarche and in postmenopausal women, the disease is less common. Most researchers believe that the true incidence of VVC is unknown due to the high percentage of self-medication among patients.

Classification

VVC is divided into uncomplicated and complicated.
Uncomplicated VVC (acute VVC) is diagnosed if all the criteria are present:
sporadic or infrequent VVC;
mild or moderate VVC;
caused C. albicans;
in patients with normal immunity.
Complicated VVC is diagnosed if at least one criterion is present:
recurrent VVC (the diagnosis is made in cases where 4 or more clinically significant episodes of VVC are recorded within 1 year);
severe VVC;
candidiasis caused Candida non-albicans species in patients with reduced immunity (for example, in cases of decompensated diabetes mellitus (DM), treatment with glucocorticoids, pregnancy).
There is also candidiasis, which is characterized by the absence of patient complaints and a pronounced clinical picture of the disease. However, when microbiological research In the vaginal discharge, budding forms of yeast fungi are found in small quantities in the absence of pseudomycelium in most cases.

Etiology and pathogenesis

The causative agents of VVC are yeast-like fungi of the genus Candida, numbering more than 170 species, including C. albicans, causing VVC in 75–80% of cases. In recent years, there has been a trend towards an increase in the spread of VVC caused by "non-albicans"-types: C. glabrata, C. tropicalis, C. paparsilosis, C. crusei, C. lusitaniae, Saccharomyces cerevisiae. These species of the genus Candida, as a rule, contribute to a complicated course of the disease, which is difficult to respond to antimycotic therapy.
The pathogenesis of VVC is complex and remains poorly understood. Considering the fact that the strains C. albicans, isolated from patients with vulvovaginal candidiasis and from carriers, do not differ significantly in a number of biochemical characteristics, we can draw a conclusion about the leading role of the state of the macroorganism in the development of vulvovaginal candidiasis, and not the properties of the pathogen. The trigger for the development of the disease is not a change in the properties of the fungus, but a decrease in the resistance of the host organism.
The following stages are distinguished in the development of candidiasis:
attachment (adhesion) of fungi to the surface of the mucous membrane with its colonization;
penetration (invasion) into the epithelium, overcoming the epithelial barrier of the mucous membrane, entering the connective tissue of the lamina propria, overcoming tissue and cellular defense mechanisms;
penetration into blood vessels, hematogenous dissemination with damage various organs and systems.
For vaginal candidiasis infectious process most often localized in the superficial layers of the vaginal epithelium.

Morphology and physiology of fungi of the genus Candida

Mushrooms of the genus Candida consist of oval budding yeast cells (4–8 μm) pseudohyphae and septate hyphae. For C. albicans Characteristic is the formation of a growth tube from blastospores (buds) when they are placed in serum. Besides, C. albicans forms chlamydospores - thick-walled, double-circuited, large oval spores. On simple nutrient media at 25–27°C they form yeast and pseudohyphal cells. Colonies are convex, shiny, creamy, opaque. In tissues, Candida grows in the form of yeast and pseudohyphae (Fig. 1, 2).

Predisposing factors

Mushrooms of the genus Candida are part of the normal vaginal microflora. However, under the influence of certain exo- and endogenous factors (broad-spectrum antibiotics, immunodeficiency states, human immunodeficiency virus, tuberculosis, diabetes, thyroid pathology, sexually transmitted infections, etc.), candidiasis becomes a clinically pronounced form (Fig. 3 ).
Genital candidiasis is often accompanied by asymptomatic candidoria, urethritis and other urinary tract diseases. In the pathogenesis of genital candidiasis, long-term use of hormonal (oral) contraceptives plays a certain role, affecting the ratio of hormones that regulate reproductive function. Virulence C. albicans increases in conditions of high humidity (sweating). Triggers for the development of hypersensitivity and predisposition to colonization of fungi of the genus Candida are:
wearing tight synthetic underwear,
washing off with a pressure shower,
use of sprays,
use of gaskets (Fig. 3).

Screening

Patients with complaints of cheesy vaginal discharge, itching, burning, dyspareunia, and pregnant women are subject to examination for VVC. Screening is carried out using a microscopic examination of vaginal discharge.

Diagnostics

Clinical picture

The clinical picture of VVC varies and depends on a number of factors, including the type of pathogen. The most common symptoms of VVC include the following clinical signs:
copious discharge from the genital tract of various colors and consistency: white, thick (creamy) or flaky, cheesy, filmy, with a mild sour odor, occasionally watery, with cheesy-crumbly inclusions;
itching and burning in the vagina and vulva; itching, as a rule, is intense, accompanied by scratching, often leading to insomnia and neuroses;
hyperemia, swelling, rashes in the form of vesicles on the skin and mucous membranes of the vulva and vagina;
The above symptoms can often interfere with urination, causing urinary retention.
Recurrent VVC is diagnosed when there are 4 or more episodes of VVC per year and occurs in 17–20% of women with VVC. There are 2 main mechanisms for the occurrence of chronic recurrent candidiasis:
vaginal reinfection;
relapse associated with incomplete elimination of the pathogen.
The clinical picture of recurrent VVC is characterized by less widespread lesions, less intense hyperemia and swelling; vaginal discharge is less abundant or may be absent. On the skin and mucous membranes of the genital organs, secondary elements predominate in the form of infiltration, lichenification and tissue atrophy. In addition, the process can spread to the perianal area, as well as to the inner thighs. As a rule, the symptoms of the disease develop rapidly a week before menstruation and subside slightly during menstruation (Table 1).


The consequences of the complicated form of VVC are:
generalized candidiasis in patients with immunodeficiency conditions;
recurrent urinary tract infections;
miscarriage;
birth of low birth weight babies;
chorioamnionitis;
premature rupture of membranes;
premature birth.

Laboratory and instrumental research

Diagnosis of VVC must be comprehensive. Leading role in diagnostics along with clinical symptoms belongs to microbiological research methods (microscopy of smears of vaginal discharge and cultural research method), diagnostic value which reaches 95%. Cultural method - sowing material on nutrient medium allows you to determine the number, genus and species of fungi, their sensitivity to antifungal drugs, as well as the nature and degree of microbial contamination with other opportunistic bacteria. Microscopic examination is one of the most accessible and simple methods diagnostics The study is carried out in native and Gram-stained preparations. In recent years, express diagnostic methods have been used, which in the shortest possible time with fairly high accuracy make it possible to identify fungal strains using ready-made test systems with favorable environments for fungal growth. The use of express diagnostics is very promising, does not require much time, and does not cause difficulties, but its results do not allow us to judge the accompanying flora.
In severe, recurrent forms of VVC, accompanied by disorders in the immune system, it is possible to determine antibody titers to fungi of the genus Candida in blood serum. But this research method is practically not used due to the high frequency of false negative and false positive results.
The colposcopic diagnostic method is not specific. It reveals changes in the epithelium characteristic of the inflammatory process, but does not allow determining the etiology of the disease.
Molecular biological methods (real-time polymerase chain reaction (PCR) aimed at detecting specific fragments of deoxyribonucleic acid or ribonucleic acid Candida spp..) are not mandatory methods for laboratory diagnosis of VVC.
Depending on the concentration of yeast-like fungi of the genus Candida and the nature of the accompanying microflora in the vaginal biotope, 3 forms are distinguished Candida vaginal infections:
asymptomatic carrier;
true candidiasis (a high concentration of fungi is combined with a high concentration of lactobacilli);
a combined form of bacterial vaginosis with VVC (fungi vegetate with an overwhelming predominance of obligate anaerobes).

Differential diagnosis

It is advisable to carry out differential diagnosis of VVC with:
bacterial vaginosis;
genital herpes;
aerobic vaginitis;
skin diseases(eczema, lichen planus, scleroderma, Behcet's disease, etc.).
In clinical practice, most often the differential diagnosis of VVC should be carried out with bacterial vaginosis and trichomoniasis (Table 2). Differential diagnosis of vaginal pathology is presented in Table 2.

Treatment

Target drug treatment VVC – pathogen eradication. Most cases of VVC can be treated with topical antifungals and antiseptics.
The advantages of local agents include their safety, high concentrations of antimycotics created on the surface of the mucous membrane, and a lower likelihood of developing resistance. In addition, many antimycotics local action provide relief of symptoms faster, mainly due to the ointment base. In case of severe symptoms of the disease, preference is given to systemic drugs.
Among systemic drugs fluconazole is used, which was previously prescribed once in the treatment of VVC; subsequently, the drug was recommended to be used three times. In the treatment of VVC caused by fungi Candida non-albicans, the prevalence of which has been steadily increasing recently, the use of fluconazole is ineffective. In this regard, the relevance of the use of other groups of antifungal drugs, including clotrimazole, is increasing.
Local antifungal agents are produced in special forms: vaginal suppositories and tablets, creams, douching solutions. The arsenal of vaginal forms of antimycotics in Russia is constantly changing, which sometimes misleads doctors regarding the currently available drugs. Vaginal forms of isoconazole, clotrimazole, miconazole, econazole, etc. are registered in Russia.
Vaginal creams are recommended for the treatment of vulvitis, a combination of vulvitis and vaginitis, tablet forms and suppositories are recommended for the treatment of vaginitis. The drugs are usually administered at bedtime using the supplied applicators (creams) or fingertips (suppositories).
Intravaginal and oral administration drugs are equally effective (level of evidence ΙΙ, class A). However local forms safer, because they have virtually no systemic effect and create high concentrations of the active substance at the site of application.
The following main antifungal drugs are used:
polyene series (natamycin, nystatin);
imidazole series (clotrimazole, sertaconazole, ketoconazole, butoconazole, fenticonazole, miconazole, econazole, omoconazole, ternidazole, etc.);
triazole series (fluconazole, itraconazole);
others (iodine preparations, etc.).
Despite the rapid development of the pharmacological industry and a huge selection of antimycotic drugs, the problem of treating vulvovaginal candidiasis does not lose its relevance. Considering the high frequency of the disease, long course, and frequent recurrence of the process, it can be assumed that, most likely, it is based on an unfounded approach to the diagnosis and treatment of this disease. The causative agent of chronic recurrent vulvovaginitis in 85% of cases is a mixed candidal infection, resistant to widely used antimycotic agents. In this regard, the use of antimycotic drugs that also have an antimicrobial effect on the accompanying microbial flora is of fundamental importance. An example of such a drug is clotrimazole (imidazole series), which is effective against dermatophytes, yeasts, molds and protozoa. Has an antimicrobial effect against gram-positive ( ) and anaerobes ( ). Clotrimazole has no effect on lactobacilli. In vitro, at a concentration of 0.5–10 μg/ml, clotrimazole inhibits the proliferation of bacteria of the Corinebacteria family and gram-positive cocci (with the exception of enterococci); has a trichomonacid effect at a concentration of 100 mcg/ml.
When using clotrimazole intravaginally (tablets - 100, 200, 500 mg; suppositories - 100 mg), absorption is 3-10% of the administered dose. High concentrations in vaginal secretions and low concentrations remain in the blood for 48–72 hours. In the liver it is metabolized to inactive metabolites, excreted from the body by the kidneys and through the intestines.
Clotrimazole 2% cream (10 mg), used for external use, due to the action of the active substance (clotrimazole), penetrates into the fungal cell and disrupts the synthesis of ergosterol, which is part of the cell membrane of fungi, which changes the permeability of the membrane and causes subsequent cell lysis. At fungicidal concentrations, it interacts with mitochondrial and peroxidase enzymes, resulting in an increase in the concentration of hydrogen peroxide to a toxic level, which also contributes to the destruction of fungal cells. In the same way, Clotrimazole affects pathogenic bacteria (Gram-positive ( Streptococcus spp., Staphylococcus spp..) microorganisms and anaerobes ( Bacteroides spp., Gardnerella vaginalis)), which cause vulvitis and vaginitis.
The advantage of using 2% Clotrimazole cream over other forms of antimycotics is that this form effective in the treatment of recurrent candidal vulvitis with the addition of a bacterial infection in women, as well as for the treatment of balanoposthitis in their sexual partners, due to the antimicrobial effect of the drug. Treatment with Clotrimazole (2% cream) for men should begin immediately when the first symptoms of the disease appear. An advanced infection can develop into a chronic form or provoke serious consequences– the appearance of prostatitis and vesiculitis. In some cases, fungi can infect bladder and kidneys.
In addition, 2% Clotrimazole cream is advisable to use in the treatment of vulvitis in HIV-infected patients and patients with diabetes mellitus due to the frequent presence of severe forms of recurrent VVC in these patients.
The advantages of 2% Clotrimazole cream over 1% cream are a higher concentration of the active substance at the site of application and, therefore, a reduction in the duration of the course of treatment - 2% cream is used to treat VVC once a day for 3 days, 1% cream - 1 once a day for 7 days.
The main advantages of Clotrimazole over other antifungal agents are:
effective effect on pathogenic forms of fungi and accompanying bacterial flora - gram-positive ( Streptococcus spp., Staphylococcus spp.) and anaerobes ( Bacteroides spp., Gardnerella vaginalis), clotrimazole inhibits the proliferation of bacteria of the family Corinebacteria and gram-positive cocci (except enterococci); has a trichomonacid effect, leading to the death of trichomonas and, accordingly, to a complete cure for the disease;
minimal number of contraindications for use and side effects, which is associated with local application clotrimazole;
economic availability of the drug.

Basic preventive measures

Recovery will be facilitated by continuous prevention of VVC, which should include the following recommendations for patients:
use during sexual intercourse barrier method protection (condom); It is especially important to follow this rule for women who do not have a permanent sexual partner;
conduct an examination of the body and identify hidden diseases(especially the genitourinary system);
refuse sexual contact with a person sick with candidiasis until he recovers;
treat the underlying disease that provoked a decrease in immunity;
If possible, abandon hormonal contraceptives, under the influence of which hormonal background becomes a favorable basis for the growth of fungi;
when treating with antibiotics, additionally use antimycotic drugs;
refuse, at least partially, from underwear made of synthetic materials;
maintain intimate hygiene;
give up strict diets and eat rationally;
do not abuse alcoholic beverages, stop smoking.

Observation and further management

The criteria for the effectiveness of VVC treatment are the disappearance of symptoms of the disease in combination with negative results of microbiological testing.

Forecast

The prognosis is favorable.

Literature

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Most women have experienced vulvovaginal candidiasis at least once during their lives. In 40–45% of patients, the disease recurs, and 5% of women suffer from a chronic form of the pathology.

Many people underestimate the danger of a fungal infection and ignore its first symptoms. Without adequate treatment, the disease progresses and reduces the quality of life. Pathogenic microorganisms spread to healthy tissue and create new lesions. The longer vulvovaginal candidiasis develops, the more difficult it is to cure.

About the disease

Vulvovaginal candidiasis is an infectious disease that is accompanied by inflammation of the mucous membrane of the vulva, vagina, urethra and perineal skin. Its causative agents are yeast-like fungi of the genus Candida. Vulvovaginal candidiasis is most often caused by the species. From 80 to 92% of episodes of pathology fall on its share. In other cases, representatives are identified:

• C. glabrata;
• C. tropicalis;
• C. guillermondii;
• C. parapsilosis;
• C. Kefir.

The cells of fungal microorganisms have a round shape. Their sizes range from 1.5 to 10 microns. Yeast-like fungi create pseudomycelium, which is formed due to the elongation of their cells. The causative agents of the disease are anaerobes. These are organisms that require oxygen to support the process of energy synthesis. Candida fungi actively reproduce in conditions of high humidity and at temperatures of 20–37 °C. The most favorable pH level for them is 6.0–6.5.

Yeast-like fungi Candida are widespread in nature. They are found in vegetables, fruits, dairy products, and also on the surfaces of objects. They are resistant to adverse conditions. Fungal microorganisms die only after prolonged boiling (10–30 minutes). They remain viable for half an hour when exposed to dry steam at a temperature of 95–110 °C. Fungi can withstand very acidic environments (pH 2.5–3.0) for long periods of time, although their development is slowed down under such conditions.

Based on the nature of its course, vulvovaginal candidiasis is divided into acute and chronic. The first form of the disease lasts no more than 2 months. Chronic pathology can be recurrent and persistent. The first periodically worsens - at least 4 episodes per year. Between them, the woman feels completely healthy. In the persistent form, the symptoms of the disease are observed constantly, sometimes decreasing, sometimes increasing.

Fungal infection most often develops in women of reproductive age. The peak incidence occurs between the ages of 20–45 years.

Reasons for development

Candida fungi are considered opportunistic microflora. They are present in small quantities on the skin and mucous membranes of healthy people, without causing the development of diseases. Fungal microorganisms are necessary. They help dispose of dead and dangerous cells.

The number of colonies of fungal flora is controlled by the immune system and beneficial bacteria, which are part of the human microbiocenosis. That's why healthy people rarely encounter fungal diseases and do not know what it is.

Uncontrolled use of medications

Candida fungi acquire pathogenic properties when the immune system weakens or the number of beneficial microorganisms sharply decreases.

The widespread use of fungal infections contributes to:

• antibiotics;
• cytostatics;
• immunosuppressants;
• hormonal drugs (especially first generation);
• oral contraceptives.

Poor personal hygiene

The development of the disease is provoked by vaginal tampons and sanitary pads. Because of them, a favorable environment for the proliferation of fungal microorganisms is created in the perineal area.

Pregnancy

Pregnancy influences the development of fungal disease. During pregnancy, the likelihood of vulvovaginal candidiasis increases by 2–3 times. The main causes of the disease include an increase in the concentration of estrogens and progestins in tissues.

Recurrent forms of vulvovaginal candidiasis often develop against the background of impaired carbohydrate metabolism in patients with diabetes mellitus. They are characterized by frequent exacerbations and are difficult to treat.

Chronic vulvovaginal candidiasis is often a consequence of self-medication. Advertising of antifungal drugs and their availability cause uncontrolled use of medications.

Incorrectly selected medications do not suppress the reproduction of pathogens, while weakening the body's defenses.

Severe forms of vulvovaginal candidiasis occur as a result of low patient compliance. This term refers to the degree to which the patient complies with the doctor’s recommendations. If the patient voluntarily shortens the course of treatment and reduces the dosage of drugs, fungal microorganisms survive and become resistant to the drug. In this case, it becomes more difficult to achieve a therapeutic effect.

Characteristic symptoms

The acute form of vulvovaginal candidiasis is characterized by pronounced symptoms. A woman suffers from unbearable itching in the vulva and vagina. It intensifies in the evening, at night, and also after a long walk. The itching is so severe that the patient cannot resist scratching.

As a result, micro-wounds appear on the mucous membrane, through which pathogens penetrate deep into the tissues. Due to severe itching, which can also occur in the anal area, sleep is disturbed and neuroses develop.

In addition to itching in the genital area, burning and pain are noted, especially in the scratching area. Unpleasant sensations intensify during urination, preventing complete emptying of the bladder.

Excruciating itching, burning and pain accompany sexual intercourse. Over time, a woman develops a fear of sexual contact.

A characteristic sign of vulvovaginal candidiasis is the appearance of leukorrhea (leukorrhea). They may have a thick (creamy) or flaky consistency. The gray-white discharge looks a little like cottage cheese and has a mild sour odor. Sometimes they are watery with cheesy clots that look like crumbs. In some cases, the disease proceeds without the formation of leucorrhoea.

The skin in the affected area turns red, swells and softens. On it you can find small red nodules and gray-white deposits of a round or oval shape. The size of cheesy spots with a sour odor can reach 5–7 mm in diameter. They can merge into large formations with clear boundaries, surrounded by areas of severely reddened mucous membrane. They contain a huge amount of quickly multiplying Candida fungi.

If candidiasis is diagnosed in the acute stage, plaque is difficult to remove. Beneath them, a bleeding, eroded surface is exposed. In the chronic form of the disease, it is easy to get rid of cheesy films. After removing plaque from the tissues of the mucous membrane, a whitish cheesy liquid is released abundantly.

Symptoms usually begin a week before your period. During bleeding they appear less intensely.

In the chronic form of the disease, the mucous membrane of the genital organs becomes thick, dry and rough. Areas with signs of atrophy appear on it.

Treatment of the disease

On initial stage To treat diseases, medications with antimycotic effects and antiseptics for external use are used. They allow you to create a high concentration of the active substance in the affected area, with minimal impact on the entire body.

If vulvar candidiasis is diagnosed, creams are used. When the vaginal mucosa is affected, suppositories, solutions and vaginal tablets are used.

During pregnancy, it is allowed to use antifungal agents in the 2nd and 3rd trimester, giving preference to topical drugs. Systemic medications are prescribed in extreme cases when the benefit to the mother outweighs the potential harm to the fetus.

Polyenes are used to treat fungal infections:

• Nystatin;
• Levorin;
• Amphotericin.

Imidazoles:

• Isoconazole;
• Ketoconazole;
• Bifonazole;
• Miconazole;
• Clotrimazole.

Triazoles:

• Fluconazole;
• Itraconazole

Fluconazole is considered the “gold standard” for the treatment of vulvovaginal candidiasis. Fungi of the species Candida Albicans are especially sensitive to it.

The lesions are treated with antiseptic solutions ( baking soda, boric acid, potassium permanganate). They are used for baths, douches or for wetting vaginal tampons. The doctor applies aniline dyes to the vaginal mucosa.

Shown antiseptic drugs in the form of suppositories (Betadine, Vocadine, Iodoxide). They are administered before bedtime. Boric acid can be prescribed in the form of vaginal capsules. In severe cases, hormonal creams (class 1 and 2 corticosteroids) are used.

Treatment of fungal infections is difficult due to the rapidly developing resistance of pathogens to medicines. Fungal cells mutate and produce enzymes that reduce the effect of the drug on them. They acquire “pumps” that literally release the active substance from the cells.

In order to overcome the problem of resistance of pathogenic microorganisms, a fundamentally new antimycotic drug Sertaconazole was created. Its molecule contains azole and benzothiaphene structures that reinforce each other. A single use of Sertaconazole for external use in the form of suppositories or cream is recommended.

Treatment of complicated forms of vulvovaginal candidiasis

Often, a fungal disease is complicated by a bacterial infection. In such cases, treatment of vulvovaginal candidiasis is carried out with complex preparations containing, in addition to antimycotics, antibacterial, hormonal or antiseptic substances.

The drug Macmiror contains the antimycotic Nystatin and the antibacterial agent Nifuratel. Macmiror is used externally and in the form of suppositories.

The combination of antimycotics with Metronidazole is justified. It is active against bacteria and protozoa. Used for the treatment of vulvovaginal candidiasis complex drug Neo-Penotran in the form of vaginal suppositories. They contain Miconazole and Metronidazole.

Combination agents have been successfully used: Travocort (Isaconazole nitrate + Difluorocortolone-21-valerate), (Miconazole + Metronidazole), Polygynax (Nystatin + Neomycin + Polymyxin) and Terzhinan (Nystatin + Neomycin sulfate + Ternidazole + Prednisolone).