Abstract

Vulvovaginal candidiasis occurs due to the overgrowth of Candida Spp. is frequently encounteredduring late pregnancy. Multiple factors predispose to such infection including – host immune mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and estrogen secretion.

This case study reports whitish vaginal discharge, itchiness and burning sensation in the vagina and vulva of a 24-year-old woman at 21 weeks of gestation. The patient had had similar symptoms in the past; this was her first pregnancy. The lady was diagnosed with vulvovaginal candidiasis due to Candida albicans infection. She was successfully treated with topical ciclopirox olamine application for one week. Continued usage was advocated for the prevention of recurrent symptoms.

Introduction

Topical antifungal agents are usually advocated for use in pregnant women with skin and mucocutaneous fungal infections. Whereas, the use of corticosteroids is contraindicated during pregnancy. Among the antifungal agents, econazole must be avoided during the first trimester and may be used sparingly during 2nd and 3rd trimester. While ketoconazole and selenium sulphide are likely safe, but should be employed in limited areas for brief periods.¹

Vulvovaginal candidiasis occurs due to the overgrowth of Candida Spp. is frequently encountered post menopause and during late pregnancy. Multiple factors may predispose to such infection including – host factors of local defense mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and estrogen secretion.Non-albicans species, particularly Candida glabrata, and rarely Saccharomyces cerevisiae, also account for less than 10% of all cases of vulvovaginitis with some regional variation—these are generally associated with milder signs and symptoms than normally seen with a Candida albicans-associated vaginitis.²

Characteristic features include premenstrual itching, burning, redness and odorless discharge. Evaluation of vulvovaginal candidiasis involves a detailed medical history, clinical examination and microscopic examination of the vaginal content. In chronically recurring cases, a fungal culture for pathogen determination should be performed.²

Case Report

A 24-year-old primi gravida complained of white curd-like vaginal discharge, burning sensation in the vagina and vulva along with an itchy rash, at 21 weeks of gestation.

The lady did not have any other medical ailments. She reported of having similar symptoms in the past.

A wet mount of vaginal swab confirmed Candida albicans overgrowth. The patient was diagnosed with vulvovaginal candidiasis.

The patient was prescribed a 2% ciclopirox olamine cream. Her symptoms attenuated within one week of this topical therapy. Continued application for another week prevented the recurrence of the infection.

Discussion

Certain antifungal agents like oral triazoles – for example, fluconazole and itraconazole, are contraindicated in pregnant women. Topical agents are usually preferred for symptomatic relief and eradication of the cause. Topical ciclopirox olamine (CPO) has been found to be effective in ameliorating symptoms of vulvovaginal candidiasis caused due to C. albicans colonization and is safe for use in pregnant women with skin and mucocutaneous fungal infections. Meanwhile, Candida krusei is resistant to the triazoles; in patients with C.krusei infection, ciclopirox olamine has been found to be efficacious.²

Ciclopirox – a hydroxypyridone, is the main ingredient of ciclopirox olamine which is available as ointments, creams, gels and shampoos. This drug is used for treating skin and mucocutaneous fungal infections, such as dermatophytosis and vulvovaginal candidiasis, is a pregnancy category B drug and can also be used in patients over 10 years of age. CPO is particularly effective in the management of athlete’s foot and onychomycosis—when used as a nail lacquer. This drug compares very well with oral antimycotic agents in terms of the benefit/risk ratio because of its excellent tolerability and complete absence of serious adverse effects.^1,3

Conclusion

This case study describes a 24-year-old primi gravida with white curd-like vaginal discharge, burning sensation in the vagina and vulva along with an itchy rash, at 21 weeks of gestation. A detailed history revealed that the patient had experiences similar symptoms in the past. Wet mount of vaginal swab confirmed Candida albicans overgrowth. The patient was diagnosed with vulvovaginal candidiasis.The lady was treated with 2% CPO cream. Her symptoms attenuated within one week of this topical therapy. Continued application for another week prevented the recurrence of the infection.

CPO is available as ointments, creams, gels and shampoos. This drug is used for treating skin and mucocutaneous fungal infections, such as dermatophytosis and vulvovaginal candidiasis. It is a pregnancy category B drug and has shown safety when used in pregnant women, as well as children with skin fungal infections.

References

1. Patel VM, Schwartz RA, Lambert WC. Topical antiviral and antifungal medications in pregnancy: a review of safety profiles. J Eur Acad Dermatol Venereol. 2017;31(9):1440-1446. doi:10.1111/jdv.14297
2. Mendling W, Brasch J, Cornely OA, et al. Guideline: vulvovaginal candidosis (AWMF 015/072), S2k (excluding chronic mucocutaneous candidosis) [published correction appears in Mycoses. 2015 May;58(5):324. Multiple author names added.]. Mycoses. 2015;58 Suppl 1:1-15. doi:10.1111/myc.12292
3. Sonthalia S, Agrawal M, Sehgal VN. Topical Ciclopirox Olamine 1%: Revisiting a Unique Antifungal. Indian Dermatol Online J. 2019;10(4):481-485. doi:10.4103/idoj.IDOJ_29_19