Candidal vulvovaginitis

　　80-90% of vulvovaginal candidiasis (VVC) is caused by Candida albicans, while a small number of VVC cases can be attributed to Candida glabrata, Candida parapsilosis, or Candida tropicalis, among others. Candida albicans is an oval, monolayered cell that distributes in clusters, forming pseudohyphae through the budding spores and elongation of the cells. Candida is not heat-tolerant and can be killed by heating to 60℃ for one hour, but it has strong resistance to drying, sunlight, ultraviolet light, and chemical agents. Approximately 10% of non-pregnant women and 30% of pregnant women have Candida colonization in the vagina without symptoms. When the vaginal glycogen increases and the pH value decreases, Candida is prone to reproduce and cause inflammation, hence it is more common in pregnant women, diabetes patients, and those using estrogens; long-term and excessive use of antibiotics can suppress the normal vaginal flora, leading to overgrowth of Candida; long-term use of immunosuppressants or glucocorticoids can lower the patient's immune function. These factors can all promote vaginal infections and lead to VVC.

　　1. Vaginitis can cause other diseases. If fungal vaginitis is not treated for a long time, it can easily cause inflammation to ascend, leading to cervicitis and cervical erosion. If the pathogen enters the uterine cavity, it can cause salpingo-ovarian inflammation, pelvic inflammatory disease, and eventually affect pregnancy.

　　2. Vaginitis can affect the quality of life. Women with candidal vaginitis may experience symptoms such as vulvar itching, which can cause many inconveniences and impacts on their lives and work, and may also affect their sexual life.

　　3. Vaginitis can cause infertility. Normally, the vagina has a relatively safe environment with a balanced flora and pH. This environment is important for the temporary storage of sperm and passage. Once this environment is destroyed, infertility is more likely to occur.

　　4. Vaginitis can affect fetal development. After the pregnant woman becomes ill, a small number of Candida can ascend through the cervix, penetrate the amniotic membrane to infect the fetus, and cause preterm labor.

　　5. Fungal vaginitis during pregnancy often leads to adverse perinatal outcomes such as chorioamnionitis, amniotic fluid infection, premature rupture of membranes, preterm labor, and endometritis after cesarean section or vaginal delivery. Therefore, it is relatively safe for women to become pregnant after recovery.

　　Vulvar itching and a large amount of white curd-like vaginal discharge are the main symptoms of the disease. It may be accompanied by vulvar burning sensation, urgency, dysuria, and pain during sexual intercourse. In severe cases, the patient may be restless and extremely painful.

　　1. Fungal vaginitis can be transmitted between couples, so if the female partner finds a candidal infection, the male partner should also be examined.

　　2. It is recommended for patients with tinea pedis to separate the washing of their underwear and socks, and ideally expose them to sunlight for more than one hour. If conditions do not allow, boil them for 15-30 minutes.

　　3. Pay attention to the rational use of antibiotics or estrogens and timely treatment of diabetes.

　　4. Avoid sexual activity or use a condom during treatment, avoid vaginal medication and sitting in a bath during menstruation. For those who frequently relapse, perform local irrigation and medication one week before each menstrual period and one week after the menstrual period, continue to irrigate and medicate for three months, and a negative vaginal discharge is considered cured after re-examination.

　　5. Oral medications during pregnancy can affect the fetus, so local treatment is preferred, and the operation should be gentle to avoid causing abortion or preterm labor.

　　6. Advocate for showering without using others' bath towels, basins, buckets, etc., avoid wearing tight clothes, synthetic clothes, and not using sanitary napkins, and wear cotton underwear to ensure cleanliness and dryness of the lower body.

　　7. Avoid unclean sexual intercourse.

　　8. Prevent cross-infection in the hospital, strictly disinfect equipment, clothing, and other items, and ensure that each person has their own items.

　　9. Avoid sexual activity and vaginal flushing or local medication for 24-48 hours before taking the secretion. Do not perform a double and examination before taking the secretion, and do not apply lubricant to the speculum to prevent misdiagnosis.

　　1. Direct examination method: It is the most commonly used clinical examination method, with a positive detection rate of 60%. Its advantages are simplicity and speed. Use a longer disinfected cotton swab to take vaginal, cervical secretions, or the milky white film on the vaginal wall as the specimen to be examined.
　　(1) Saline method: Take a small amount of vulvar and vaginal secretion, spread it on a slide, add 1 to 2 drops of physiological saline to mix.
　　(2) Potassium hydroxide method: Take a small amount of secretion and place it on a slide, add 1 drop of 10% potassium hydroxide solution or isotonic sodium chloride solution, cover it with a coverslip, and examine it under a microscope. After mixing, find the blastospores and pseudohyphae under the microscope. If there are more pseudohyphae, it indicates that Candida is in the pathogenic stage, which is more significant for diagnosis. Since 10% KOH can dissolve other cell components, the detection rate of Candida albicans is higher than that of physiological saline. The positive rate of examination for asymptomatic carriers is 10%, and the positive detection rate of symptomatic vaginal inflammation is 70% to 80%.
　　2. Gram staining method: The positive detection rate of this method is 80%. Take the secretion, make a smear, fix it, perform Gram staining, and observe under a microscope. A group of Gram-positive oval spores and pseudohyphae can be seen. The positive rate of Congo red staining or PAS staining is higher than that of direct microscopic examination. Gram staining, the spores and pseudohyphae are stained blue. Congo red and PAS staining, the spores and pseudohyphae are stained red.
　　3. Culture method: Take the specimen and inoculate it on Sabouraud's culture medium, place it in a 37℃ incubator, and observe after 24-28 hours. A large number of small and white colonies can be seen. Pick up a small amount of colonies with a loop and make a smear for direct microscopic examination or staining after examination, and a large number of blastospores can be seen, which can be preliminarily diagnosed as candidal infection. The culture positivity rate is almost always 100%. The main observation of Candida albicans culture is the colony morphology, color, odor, and microscopic performance. First, check the entire culture plate under 10 times magnification, which is enough to distinguish yeast cells, pseudohyphae, and protoplast spores. Further, the consumption of sugar, nitrogen-containing compounds, and vitamins can be detected by biochemical methods to distinguish different species.
　　4. Bacterial strain identification: To determine the species of Candida, fermentation tests and assimilation tests must be performed, and the colony morphological characteristics should be identified.
　　5. pH value measurement: It has important differential diagnostic significance. If the pH value is 4.5, it may be a simple infection caused by Candida albicans. If the pH value is 4.5 and there are a large number of white blood cells in the smear, it suggests a mixed infection with Trichomonas or bacterial vaginosis.
　　6. For elderly and obese patients or those with long-term treatment without improvement, urine sugar and blood sugar should be checked to find the cause of the disease.
　　7. Use immunodiffusion or latex agglutination method: white candidal antibodies can be detected.

　　1. Choose a diet that is light and rich in vitamins A, B2, C, and others, such as animal liver, fish eggs, carrots; poultry eggs and fresh vegetables, such as tomatoes, spinach, amaranth, soybeans, mung beans, lotus root, etc.; and eat fresh fruits, such as oranges, tangerines, pomelos, lemons, strawberries, hawthorn, and others.
　　2. Women with vulvar itching should consume nutrient-rich foods, such as chicken, milk, tofu, and legumes.
　　3. Adequate intake of vitamin A, vitamin B2, and folic acid, such as cod liver oil, carrots, animal liver, fish, apricots, whole wheat, pumpkin, and other foods can alleviate itching symptoms, but should not be taken in excess.
　　Foods to avoid:
　　(1) Allergenic foods. Such as sea fish, shrimp, crab, river fish, lake fish, etc., after eating, they can exacerbate the itching of the external vulva, so they should be avoided.
　　(2) Tobacco and alcohol. Because they can exacerbate inflammation and congestion, making vaginal itching worse, they should be avoided.
　　(3) Spicy and刺激性 foods. Such as chili, pepper, fennel, Sichuan pepper, onion, etc., can cause inflammation to spread, and the itching of the vulva becomes more severe, so they should be avoided.
　　(4) Fried and sweet foods. Such as lard, butter, butter, fried pork chop, fried beef chop, sugar, chocolate, etc., have the effect of moistening, which is not conducive to treatment, so they should be avoided.

　　1. Imidazole derivatives:Imidazole derivatives are a class of antifungal drugs that have developed rapidly in recent years. They are mostly used locally, with definite efficacy, few side effects, but a high recurrence rate. Among imidazole derivatives, Clotrimazole and Thi康唑 are the clinical first choices due to their significant efficacy and few side effects.

　　Local medication

　　①Clotrimazole: A traditional drug. Early use was mostly Clotrimazole suppository 100mg/d, inserted into the vagina, with a course of 7 days. Now, the commonly used 500mg Clotrimazole lactate preparation (trade name Canesten) is administered vaginally as a single dose, with better efficacy than before, easier to use, and better patient compliance, and can also be used by pregnant women.

　　②Miconazole: Chemical name Dichlorophenylimidazole, trade name Daktarin. Currently widely used in China, there is also Miconazole (Daktarin) cream. It can also be used after the third month of pregnancy under the guidance of a doctor. Used once a day, one capsule at a time, for a course of 3 days.

　　③Thi康唑: Trade name Shandai, Thi康唑 vaginal ointment is given as a single dose, easy to use, with few side effects, and significant efficacy. Administered once a day before bedtime with the attached applicator, the course of treatment is 3, 6, or 14 days.

　　④Econazole: Chemical name Chlorophenylimidazole, Econazole 50mg vaginal suppository is used once daily, with a course of 15 days, or 150mg vaginal suppository used once daily, with a course of 3 days. The efficacy of both methods is similar, and the recurrence rate is relatively high.

　　⑤Butoconazole: A 2% Butoconazole vaginal cream is used for 3 days as a course of treatment, and its efficacy is slightly better than that of Clotrimazole and Econazole.

　　⑥Other imidazole derivatives: Fenticonazole, Isconazole, Thiconazole, and Oxiconazole also have certain efficacy, but Oxiconazole has a strong irritative effect on mucous membranes, with marked vaginal burning sensation.

　　Systemic medication

　　Ketoconazole: Trade name Nizoral, a broad-spectrum antifungal drug, characterized by good gastrointestinal absorption after oral administration. After a single oral dose of 200mg, the serum peak concentration reaches 3-4mg/L within 1-2 hours, with a half-life of about 8 hours. Ketoconazole is convenient to use and effective, but its side effects are significant, mainly liver toxicity.

　　2. Triazole class:

　　Local medication

　　Terconazole: Limited to local application for treatment.

　　Systemic medication

　　①Itraconazole: Trade name Sporanox, with a broad antifungal spectrum, it is rapidly absorbed after oral administration with a half-life of 17-24 hours, and its antifungal efficacy is 5-100 times better than that of ketoconazole. Common adverse reactions of itraconazole include gastrointestinal discomfort, headache, itching, and rash.

　　② Fluconazole: The trade name is Diflucan, a drug with a broad spectrum of antimicrobial activity, with high bioavailability of oral capsules, greater than 90%. It is not recommended for women during lactation to take.

　　3. Polyene:This is a class of antifungal drugs that were applied early in clinical practice and are still widely used today.

　　① The nystatin of the tetraene series has a minimum inhibitory concentration of 1.56-20g/ml for Candida albicans, and is used for treating vaginal candidiasis with 100,000 U vaginal suppositories, 1-2 tablets per day, for 14 days as a course of treatment. The long course of treatment and frequent administration are its drawbacks, and patients' compliance with the drug is poor.

　　② The nystatin of the heptane series has a narrow antibacterial spectrum and is effective only against Candida albicans.

　　③ Mepartricin (Kemiling) (mepartricin lauryl sulfate), both local and oral administration have definite efficacy, with obvious gastrointestinal reactions as side effects of oral administration. Take 100,000 units (2 tablets) once every 12 hours, for 3 days as a course of treatment.

　　4. Composite Agent:

　　Kangfu特栓 is composed of econazole, curcumin oil, and borneol. Econazole and curcumin oil have strong antibacterial activity against vaginal Gardnerella, anaerobic bacteria, and mycoplasma, and at the same time promote the recovery of the normal acidic environment of the vagina. Curcumin oil has a direct killing effect on staphylococcus, streptococcus, Escherichia coli, and viruses. Take one tablet once a day, or two tablets twice a day for severe cases, or as prescribed by a doctor.

　　Chloroquine doxycycline/progesterone (Kebaojing) tablets are a composite tablet containing 200mg of chloroquine doxycycline and 10mg of progesterone. The former is a broad-spectrum antibacterial agent effective against pathogens such as fungi and trichomonas that cause contact infections, and the latter can effectively repair the cervix-vagina mucosa. Take one tablet daily for 18 consecutive days.

　　5. Vaginal Irrigation

　　Wash the vulva and vagina with 3% sodium bicarbonate solution or 1:5000 gentian violet solution, 1-2 times a day.

　　Wash the vagina and vulva with 2% baking soda solution once a day, 10 times as a course of treatment. Generally, after washing the vagina, a vaginal medication should be inserted.

　　Apply 1% gentian violet solution to the vagina and vulva, 3-4 times a week, for 2 weeks in a row.