Treatment of vulvovaginal candidiasis in patients with diabetes

Diabetes is a known predisposing factor of vulvovaginal candidiasis, primarily because of hyperglycemia-induced alterations, including decreased random motion of neutrophils, chemotaxis, phagocytosis, and microbial killing. In addition, increased glucose levels in genital tissues enhance yeast adhesion and growth. Most study data indicate that overall yeast carriage and infection rates increase in diabetes and correlate with degree of glucose control. Thus, good control of blood glucose and treatment with an appropriate antifungal agent are important in the management of vaginal candidal infections in diabetic women. Because most of the oral and topical azoles used to treat vulvovaginitis result in comparable efficacy rates, selection of therapy should be based on factors such as causative organisms, safety and side effects, the potential for drug interactions, and patient preferences. In diabetic women, topical antifungal agents used as a first line of treatment have a better risk-to-benefit ratio than oral antifungal agents. They are associated with minimal side effects and are devoid of potential drug interactions. In addition, compounds that offer single-dose schedules are available with efficacy similar to that provided by longer- course regimens; the only single-dose topical agent widely available is tioconazole ointment. These short-course treatments allow patients who are active participants in their own diabetes management to control their vaginal symptoms with simple, easy-to-use one-time therapy. In patients treated with oral sulfonylureas, oral antifungal agents may affect glucose control because of potential drug interactions resulting in increased blood sulfonylurea levels and hypoglycemia. In addition, limited data suggest an increased prevalence of C. glabrata infections in diabetic versus nondiabetic women with vulvovaginal candidiasis, which should be considered in choosing therapy with a broad spectrum of activity to cover the potential causative organisms.