Vulvovaginal candidiasis (VVC) is a common fungal infection disease that is caused by overgrowth of Candida species especially Candida albicans in the vulvovaginal area. This condition occurs with symptoms such as itching, burning, and thick, white like curd discharge. It depends on parameters such as the last dose of antibiotics, the hormonal state (pregnancy, oral contraception), diabetes, immunosuppression, etc. Clinical signs are relied on for diagnosis and more confirmed using laboratory tests such as microscopy and culture. Topical or oral antifungal drugs are usually used to manage the condition. Measures include minimizing exposure to irritating substances and ensuring personal cleanliness. Patients presenting recurrent cases may need close monitoring and diagnostic screening for primary diseases. 

VVC is a prevalent condition in women and may affect most of them in their lifetime. It is estimated that about 75% of women will at some time develop at least one episode of VVC and about 40 to 45% of women will have recurrent episodes. It can affect any woman, at any age but it is more frequent among women of reproductive ages. It is observed more sparingly in prepubertal girls and postmenopausal women though it is not limited to these categories of the population. Concerning the prevalence or frequency of VVC, it also depends on the population type and geographical location. In general, it is more widespread among the industrialized country and most commonly seen among people aged 20 to 70. It is calculated that the rate of recurrent VVC is 5-8% in those women who have four or more episodes per year. 

Fungal Overgrowth: Under normal conditions, the vagina maintains an acidic pH level, and its microflora include various beneficial bacteria such as lactobacilli. When this equilibrium is disturbed, Candida species especially Candida albicans, can proliferate out of bound. Conditions such as antibiotic use or immunosuppression, the use of hormones, or in periods of hormonal changes also result in a decrease in the numbers of lactobacilli and the overgrowth of Candida. 

Adherence to Vaginal Epithelium: Candida also can form biofilms wherein it can adhere to the vaginal epithelial cells. This adhesion is achieved through certain proteins called adhesins on the 

Inflammatory Response: When Candida overgrows, the alerts the immune system which results in inflammation. Such inflammation is described by the presence of cytokines and other mediators that produce effects like itching, burning and swelling. 

Fungal Overgrowth: Candida is a typical component of the vaginal microbial biota in many women and men. However, the condition of overgrowth leads to the alteration of the micro flora of the vagina. 

Antibiotic Use: The use of broad-spectrum antibiotics will lessen the overall population of lactobacilli, which are essential in controlling the growth of Candida. 

Hormonal Changes: Pregnancy, oral contraceptives or postmenopausal hormones and other steroid medications also increase the risk because they alter the pH to an environment more favorable for Candida growth. 

Diabetes: The vaginal pH may be high due to poor glycemic control, and because of high glucose concentration in the vaginal secretions, candida is more likely to thrive. 

Frequency of Recurrences: It is crucial to understand that women, who have recurrent VVC, they may experience more complicated management, and their symptoms may last longer than women with only occasional infections that are four or more in a year. 

Underlying Health Conditions: Other diseases such as diabetes can make one develop VVC often and with severe symptoms due to poor management of the disease. 

Immune System Status: Patients with HIV/AIDS or other immunosuppressed patients or those on immunosuppressive therapy are at a higher risk for persistent or complicated VVC. 

Hormonal Factors: VVC may result from pregnancy, the use of its contra- ceptive pills, or hormone replacement therapy due to their hormonal effects. 

Age Group 

Reproductive Age: VVC is most often reported among women within their reproductive years especially those who are sexually active. It is uncommon among prepubescent girls and postmenopausal women, but these categories can also be affected. 

Prepubescent Girls: Less frequently infected because estrogen levels are lower, and vaginal flora is different compared with oral sex. 

Postmenopausal Women: May develop VVC because of alterations of the vaginal pH and microbial pattern brought about by the low levels of estrogen. 

Inspection: The external genitalia of a woman need to be observed for erythema, oedema or itching, the walls of vagina patency should be inspected for discharge, oedema or any non–symmetrical lesion. 

Discharge: Evaluate the discharge quality as normally it is thick and white like curd endowed with cottage like clumps, normally accompanied with mild yeast like smell. 

Tenderness: Feel the skin of the vulva and vaginal area to determine whether there is any pain or soreness. 

• Diabetes 
• Immunosuppression 
• Pregnancy 
• Hormonal treatments 

Acute: Chronic VVC is usually characterized by acute onset that symptoms include itching, burning and discharge. The infection can sometimes be cleared up with proper anti-fungal medication. 

Chronic/Recurrent: Recurrent VVC is observed in some women and is defined by the fact that episodes occur more than four times a year. Recurrent cases are potentially harder to treat and hence are likely to need a radical approach to treatment that will involve investigation for other related disorders and long-term strategies of prevention. 

Diagnosis: The signs and symptoms are irritation, redness burning and abnormality in vaginal discharge; this includes thick and white form of discharge. Microscopy of the vaginal discharge and culture with PCR sometimes plays an imperative role in making the diagnosis. 

Treatment 

Uncomplicated Vulvovaginal Candidiasis 

Antifungal Medications: 

• Topical Antifungals: Topical preparations available from stores include clotrimazole, miconazole, and tioconazole. It is normally applicable for 1 to 7 days depending on the case with the products. 
• Oral Antifungals: The best regimen for most patients is Fluconazole 150 mg one dose. 

Non-Pharmacological Measures: 

• Hygiene: Do not use products like douching and scented tampons. Loose and cotton undergarments should be worn for showering, and one should not wear any tight clothing. 
• Dietary Modifications: There are some who advise cutting down on sugar consumption, though opinions vary. 

Complicated Vulvovaginal Candidiasis 

• Recurrent Infections: Operationally, related to frequent consultation and defined as four or more consulting episodes per year. 
• Treatment: Proximal higher dose of oral fluconazole (150 mg every 72 h for 3 doses) or topical regimen for 7 to 14 days. 
• Maintenance Therapy: Recurrent cases may require weekly oral fluconazole for six months, maybe deemed appropriate. 
• Non-albicans Candida Infections: Some of the types are resistant to fluconazole. 

Management Considerations 

• Pregnancy: Specifically, antifungal agents used in topical therapy include clotrimazole or miconazole which are advocated. Topical antifungal medications are overall considered to be discouraged particularly when not recommended by a doctor. 
• Diabetes Mellitus: It is therefore possible for there to be tight glycemic control to avoid such occurrence in future. 
• Immunocompromised Patients: Perhaps needs more involved or longer-term treatment. 

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Hygiene: There is no need to use scented soap, do not douche, and should be changed with cotton underwear. 

Moisture Control: Avoid getting the skin wet in the area and do not wear wet clothes for a long time again. 

Diet: Lessen consumption of sweets and decide on using supplements. 

Avoid Irritants: Avoid using products such as soaps, shower gel, shampoos, etc., that have a smell and control chronic diseases such as diabetes. 

Alternative Therapies: Plain yogurt and coconut oil might also help, as with all snack foods, use sparingly. 

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Butoconazole: It is an effective antifungal that can inhibit the growth of yeast by changing its membrane permeability, thus causing death. 

Tioconazole: Describing it as a broad-spectrum antifungal and its mechanism of action includes interfering with cell membrane permeability to halt yeast proliferation and cause cell death. 

Clotrimazole: It is a fungicidal which has a very wide antifungal activity and interferes with the permeability of the cell membrane, which causes the death of yeast cells. 

Miconazole Vaginal: It belongs to the azole class of antifungal that inhibits cell wall formation, thereby leading to disintegration of yeast cell membrane. 

Terconazole: The medication belongs to the group of antifungal drugs acting on yeasts and moulds by changing the permeability of the cell membranes of fungal cells and thus killing them. 

Ketoconazole Topical: This is an antifungal that works in species of yeast targeting cell membrane permeability to bring about death. 

Nystatin: It is an effective antifungal that falls in the imidazole group, which inhibit the process of fungal cell membrane permeability impacting yeast cells. 

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Fluconazole: It is a synthetic oral azole antifungal which exerts its action through selective inhibition of cytochrome P-450 enzymes present in fungi and disruption of the fungal sterol, C-14 alpha-demethylase. 

Ibrexafungerp: It directs its action towards glucan synthase, which is a vital protein required in construction of 1,3-beta-D-glucan, an important part of fungal cell wall. It is used for the treatment of vulvovaginal candidiasis (VVC) and helps in preventing the reoccurrence of VFV in postmenarchal females and adults. 

Oteseconazole: This is an azole that works by interfering with the activity of the fungal enzyme sterol 14-alpha demethylase (CYP51), thereby causing a build-up of toxic 14-methylated sterols in fungi. It is for the prevention of the reoccurrence of the vulvovaginal candidiasis in the females who have a history of RVVC and are not of child bearing age. 

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Hydrocortisone Topical: Hydrocortisone is the most appropriate drug for pruritus related to vulvovaginitis due to its mineralocorticoid and glucocorticoid activity. The main therapeutic value of topical corticosteroids is due to number of anti-inflammatory actions at the topical level, which deals with inflammation due to different mechanisms—mechanical, chemical, microbial, and immunological. Topical steroids of a strong or very strong strength should not be used on the face, genitals, or armpit areas. 

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Conjugated Estrogens: The topical estrogen preparations that are employed in atrophic vaginitis and atrophic urethritis include equine estrogen, estradiol, and dienestrol. 

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Tamoxifen: A contraceptive choice for those who are very worried about estrogen intake in their system. This agent can also act as an estrogen receptor antagonist or agonist based on the type of tissue that is affected. 

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Boric Acid Suppositories: In the case of azole-resistant VVC, boric acid vaginal suppositories (600 mg) can be used daily for two weeks. It is applied as a primary or secondary treatment when the basic antifungal therapies are ineffective. 

Vaginal pH Modulation: Associated techniques involving the restoration of vaginal pH using lactic acid or hydrogen peroxide to rinse the vagina are sometimes contemplated, although these products are much less likely to be applied and not generally advised. 

Surgical Intervention: It has been reported that in rare circumstances where the VVC is persistent, unresponsive to therapy and has substantial adverse effects on the patient’s quality of life, the surgical management of vulvovaginal excision could be contemplated. This is done usually in patients with primary anatomical abnormalities responsible for the repeated infections. 

Laser Therapy: Recent research indicates that laser therapy may be applied to manage chronic and recurrent VVC since it appears to change the vaginal mucosa, though this is not fully experimented and authorized. 

Adjunctive Procedures: If there is a history of concurrent vulvar dermatological disease such as lichen sclerosus contributing to VVC, then excisional biopsy or other dermatological interventions may be warranted. 

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Acute Treatment: Start with antifungal creams like azoles including clotrimazole or miconazole and use oral fluconazole for severe infections. Course of treatment normally ranges from 1 to 7 days depending on effectiveness of formulation and severity of case. 

Symptom Relief: For manifestations such as itching, burning and discomfort, recommend the use of products such as topical anti-itch creams, and the elimination of materials such as scented products. 

Prevention and Follow-up: To help to avoid getting a recurrence, information should be given about future care, including not exposing oneself to excessive moisture and wearing cotton under-clothing. In repeated cases, one might suggest protracted anti-fungal treatment, and/or check for predisposing disorders.