KANDIDIASIS VULVOVAGINALIS

Hervina*
*Departement Of Dermatology and venereolgy
Faculty of Medicine Muhammadiyah University of North Sumatera
** Departement Farmacology Faculty of Medicine Muhammadiyah University of
North Sumatera

ABSTRAK
Kandidiasis Vulvovaginalis merupakan salah satu infeksi yang paling banyak
dikeluhkan wanita terutama di daerah yang beriklim tropis.(2) Sekitar 70-75% wanita
setidaknya sekali terinfeksi KVV selama masa hidupnya, paling sering terjadi pada wanita usia
subur.(2) Kandidiasis vulvovaginalis ini disebabkan oleh Candida Albican dan Candida Non
Albican (Turolopsus glabrata), dapat menyerang semua umur.(3) Pruritus akut dan keputihan
(fluor albus) merupakan keluhan awal.(3) Flour albus pada kandidiasis vagina berwarna
kekuningan.(3) Tanda yang khas ialah disertai gumpalan-gumpalan sebagai kepal susu
berwarna putih kekuningan.(3)

Evaluasi diagnostik ditegakkan melalui anamnesis, pemeriksaan fisik dan termasuk

pemeriksaan mikroskopik dengan pewarnaan Gram atau KOH 10% untuk menemukan
pseudohifa.(5) Terapi yang diberikan adalah golongan azole, flukonazol.(4)
Kata kunci : Kandidiasis Vulvovaginalis

ABSTRACT
Vulvovaginalis candidiasis is one of the most common complaints of women,
especially in tropical regions.(2) About 70-75% of women are at least once infected with KVV
during their lifetime, most often in women of childbearing age. (2) This vulvovaginal candidiasis
is caused by Candida Albican and Candida Non Albican (Turolopsus glabrata), can attack all
ages.(3) Acute pruritus and vaginal discharge (fluor albus) are initial complaints. (3) Flour albus
in yellowish vaginal candidiasis.(3) The typical sign is accompanied by clots as yellowish-white
milk head.(3)

Diagnostic evaluation is made through history, physical examination and includes microscopic
examination with 10% Gram or KOH staining to find pseudohifa. (5) The therapy given is azole,
fluconazole.(4)
Keyword : Kandidiasis Vulvovaginalis

1
INTRODUCTION Vulvovaginalis candidiasis (KVV) is
defined as one of the most common causes
Vulvovaginalis candidiasis (KVV) is a
of vaginitis, a gynecological disorder with
second-order disease of all vaginal
manifestations of white, thick, odorless
(1)
infections. KVV is an infection of the
liquid ("cottage cheese") found in the lower
vaginal mucosa and / or vulva caused by a
canal female reproduction. Accompanied
fungus of the Candida species.(1) Infection
by itching, irritation, dysuria or
can occur acutely, sub-acute and chronic,
dyspareunia.(3)
obtained either endogenously or
exogenous. (1)
Vulvovaginalis candidiasis is one of the
most common complaints of women,
especially in tropical regions.(2) About 70-
75% of women are at least once infected
with KVV during their lifetime, most often
in women of childbearing age.(2) In about
40-50 % tend to experience a recurrence or
second attack.(2) Five to eight percent of
Picture 2.1 Secret look in the vagina and
adult women experience recurrent KVV,
vulva
known as recurrent Vulvovaginalis
candidiasis (KVVR).(2) More than 33% of ETIOLOGY
the causes of KVVR are more Candida
Vulvovaginal candidiasis is caused by 81%
glabrata and Candida Parapsilosis resistant
vaginal candidiasis by Candida albicans,
to treatment.(2)
16% by Turolopsus glabrata, while the
DEFINITION other 3% is caused by Candida parapsilosis,
Candida tropicalis and Candida krusei. (5)
Candidiasis is an infection with various
The genus Candida is a unicellular yeast
clinical manifestations caused by candida,
cell that belongs to the fungus imperfecti or
specifically Candida albicans and other
deuteromycota or yeast group (yeast or
yeasts of the genus Candida.(3) Candidiasis
yeast like), including in the family of
in women generally the first infection arises
crytococcaceae which multiply by
in the vagina called vaginitis and can extend (4)
germination. This genus consists of 80
to the vulva (vulvitis), if both the vaginal
species, the most pathogenic is Candida
mucosa and vulva are infected called
albicans followed sequentially by Candida
candidiasis vulvovaginalis.(2)
2
stellatoidea, Candida tropicalis, Candida EPIDEMIOLOGY
parapsilosis, Candida kefyre, Candida
This disease is found all over the world, can
guillermondii and Candida krusei. (4)
affect all ages. (5) Fungi are found in healthy
Candida is a dimorphic (two-pole)
people as saprophytes. (5) In some countries
organism. (6) This organism can be found in
this disease remains the most among
humans in different phases of the
vaginal infections, especially in subtropical
phenotype. Morphological description of
(2)
climates and tropical climates. Sobel et
Candida in the form of yeast cells that are
al. Reported that in 20-25% of healthy
round, oval or oval in size 2-5μ x 3-6 μ to
women of reproductive age, Candida was
2-5,5μ x 5-28,5μ. (4) Candida fungi multiply
(2)
found in the asymptomatic genital tract.
with spores that grow from shoots (called
(4)
In 29.8% of women with symptomatic
blastopora.) Blastospores can be oval
vulvovaginitis can be isolated Candida
without capsules and reproduce through
fungi. (2) Average 70-75 % of adult women
bud formation, flattened hyphae, elongated
(4) have had one time suffering from vaginal
and can grow in culture or in vivo As a
candidiasis during their lifetime and 40-
sign of active budding budding (4) Based on
50% have experienced twice or more. (2)
this form, it is said that Candida resembles
Soll et al. Also reported that in women
yeast.(4) Candida mushrooms can grow with
Candida fungi were isolated, 80% of the
a wide variation in pH, but their growth will
(4)
Candida genital strains were similar to
be better at pH 4.5 to 6.5. Because
those found in the anus and 62% of Candida
Candidida albicans can produce protease
strains in the mouth were similar to those
enzymes that work optimally at normal
found in genitalia. (5)
vaginal pH. (4)
In the human body Candida is an RISK FACTORS
opportunistic fungus, which can live as
saprophytes without causing any Endogenous factors:

abnormalities. (4)
However, the fungus can a. Pregnancy, due to changes in vaginal

then turn into a pathogen and cause pH. (8)

candidiasis if there are predisposing factors b. Diabetes Mellitus, HIV / AIDS. (8)

that cause changes in the vaginal c. Intensive antimicrobial

environment. (4) administration (which changes

normal bacterial flora). (8)
d. Progesterone therapy, contraception.
(8)

e. Corticosteroid therapy. (8)

3
 f. Immunodeficiency. (8) itching.(5) Other symptoms that are felt are
heat and sometimes pain, especially during
Exogenous factors:
urination (external dysuria), during sexual
a. Personal hygiene. (8)
intercourse (dyspareunia), after a
b. Contact with patients who have high
gynecological examination or after a
sexual activity or who do not have,
shower or soaking in warm water.(8)
both young and old. (8)
Complaints are often very mild (not even
DIAGNOSIS attention of patients because they are
accustomed to) and complaints can
Anamnesis
disappear.(8)
Subjective complaints of sufferers can vary
from mild to severe.(7) Mild symptoms are Physical examination
found in infections due to Candida albicans,
Excoriation can occur, the cervix is usually
whereas Candida non-albicans, especially
normal, or slightly erythematous with white
Candida glabrata provide more severe (7)
secretions attached to the wall. On
symptoms, are relatively resistant to
examination of the vaginal mucosa, redness
treatment and often recur (KVVR).(7) Acute
and swelling of the labia and vulva are often
and vaginal pruritus (fluor albus) is an
accompanied by pustulopapular around the
initial complaint, a more frequent symptom
lesion.(7) Disease can spread to the
(3)
is vulvar pruritus. Leucorrhoea is not
perineum, vulva and the inguinal area. (7)
(3)
always present and often only slightly.
The vulva appears erythematous, edema,
Flour albus in yellowish vaginal
wet and sometimes appears papules,
candidiasis.(3) Typical signs are
vesicles, pustules, erosion and excoriation
accompanied by clots as a yellowish-white
or maceration with hyperemia in the vaginal
milk head.(3) The clot originates from a
introitus and can be found with white clots
mass released from the vulva or vaginal
and satellite lesions.(7)
wall consisting of necrotic material,
epithelial cells and fungi. (3) Supporting investigation
Vulvovaginalis candidiasis (KVV) is
Investigations that can be used to ascertain
usually accompanied by intense itching. (7)
the diagnosis of vulvovaginal candidiasis
However, this symptom is not specific
include:
because in one study it was known that only
1) Microscopic Examination: samples
38% of patients complained of severe
from pseudomembranes or vaginal
itching, but in another study 100% of
fluids are sampled and then 10%
women suffering from KKV complained of
4
 Gram or KOH staining are then
placed under a light microscope.(3)
Candida albicans will look dimorphic
with yeast oval-shaped stem cells and
hyphae.(3) And in the invasive form
candida grows as filaments, mycelia,
(7)
or pseudohifa.
Picture 2.2 Yeast Pseudohyphae
2) Culture Check: samples are cultured
on Sabouraud's dextrose or Nutrient
agar.(3) The plates are incubated at 37
° C, the colony grows after 24-72
hours, in the form of a yeast like
colony.(3) Cultures of fungi (culture)
the vagina is done to confirm the
results of negative microscopy (false
negative) that is often found in
chronic KVV and to identify non-
Candida albicans species.(3)
3) Vaginal pH Check : Vaginal pH
levels are usually normal (4.0-4.5) in
vulvovaginal candidiasis.(8) Found
more than 5 pH usually identifies BV,
trichomoniation, or mixed
(8)
infection. Examination of vaginal
pH is by placing pH paper on the
vaginal wall.(8) Avoid contact with
the cervical mucosa that has a high
pH.(8)
PATHOGENESIS
There are two important mechanisms for
understanding the pathogenesis of
vulvovaginal candidiasis.(7) The first
mechanism is how asymptomatic
colonization in the vagina changes to
symptomatic vaginitis.(7) The second
mechanism is that some women experience
recurrence and chronic Vulvovaginalis
Candidiasis infection.(7) Candida enters the
lumen vagina, especially from the perianal
area.(7) After staying and colonizing the
vagina, the organism will stay for several
weeks to months without causing
symptoms.(7) In this situation yeast cells are
usually not in the germinative phase, and
coexist with resident bacteria as.(7) If there
are several factors that change Candida
colonization (such as the use of antibiotics,
corticosteroids, diabetes and others), there
are also changes in the germinative and
filamentous phases of Candida.(7)
The germinative phase not only increases
colonization, but also plays an important
role in the invasive phase when penetrating
intact epithelial cells and attaching to the
vaginal mucosa.(7) The mushroom colonies
grow actively into mycelia and are
generally found in pathogenic conditions.(7)
If conditions permit, the disease process is
5
thought to begin from attaching Candida
cells to the vaginal epithelium which then
becomes mycelia.(7) Candida Hifa then
grows and colonizes the vaginal surface.(7)
In vitro experiments show this attachment
process.(7) Hifa grows and colonizes higher
by changes in estrogen. (7)
Picture 2.3 Pathogenesis of Vulvovaginalis
Candidiasis. (7)
PATHOPHYSIOLOGY
The manifestation of vaginal candidiasis is
the result of an interaction between the
pathogenicity of Candida and the host
defense mechanism, which is associated
(8)
with predisposing factors. In normal
circumstances, Candida fungi can be found
in small amounts in the vagina, cervix and
digestive tract.(8) Candida Mushrooms here
live as saprophytes without causing
complaints or symptoms (asymptomatic).(8)
This can support the growth of fungi which
can produce several factors that can damage
(8)
the vaginal epithelium causing vaginitis.
From the results of research that Candida-
Ag causes an increase production of
prostaglandin E2 through macrophages.(8)
The work of this prostaglandin is to inhibit
the production of cytokine-interleukin 2
(IL-2).(8) This IL-2 regulates normal T
lymphocyte proliferation.(8) Then, this will
lead to increased lymphocyte proliferation
T anti-candidal and consequently there will
be a decrease in Cell mediated immunity
(CMI).(8) This decrease in CMI causes a
person to become infected easily. candida
infection.(8)
The form of Candida filament is a form that
can usually be seen in patients with
symptomatic symptoms.(8) Forms of
filament candida can invade the vaginal
mucosa and penetrate into vaginal epithelial
cells.(8) Candida Germination will increase
colonization and facilitate tissue invasion.(8)
Sobel et al. Showed in vitro Candida fungi
that did not undergo germination or
budding, were unable to cause candidiasis
vaginalis.(7) Virulence can be extended by
the presence of proteolytic enzymes, toxins,
and fospolipase produced by yeast.(7)
Secretion aspartyl proteinase produced by
Candida spp can be identified from a
woman's vaginal secretions with symptoms
of vaginitis, but not asymptomatic.(7)
Proteolytic enzymes that contain a lot of
substrate can affect protein bonds which
will damage colonization and invasion of
fungi.(7) Some genes that can influence
proteination production (SAP1, SAP2 and
SAP3) are strongly correlated well a in vitro
6
or experimental vaginitis between gene
expression, aspartil proteinase secretion
and the ability to cause an illness.(7)
Decreased immune system and changes in
the environment of the vaginal area which
causes a decrease in local defense and
hypersensitivity reactions along with the
ability of Candida species to produce
virulence factors play an important role in
the pathogenicity of infections.(3)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of vulvovaginal
candidiasis is:
1) Trichomoniasis
Secretions are numerous and runny,
yellowish, foaming, smells bad and
rarely has skin lesions.(4)
Picture 2.4 Trichomoniasis infection
“Strawberry appearance”
2) Bacterial Vaginosis
Dilute secretions, thin
homogeneous, white or grayish and
fishy.(6) Inflammation of the vagina
and vulva is unknown.(6)
Picture 2.5 secret of vaginosis
bakterial
MANAGEMENT
a. Non pharmacology: avoid or eliminate
prediposition factors.(8)
b. Farmochology:
Candida cell walls are complex
glycoproteins that depend on ergosterol
biosynthesis.(1) Azole compounds, which
are found in antimicotic drugs, are believed
to inhibit ergosterol production, allowing
topical antimicotics to reach a cure rate of
more than 80%.(1) In general, topical
antifungal therapy quite effective,
especially if used long-term (1-2 weeks).(3)
The only oral azole agent approved for this
indication by the US Food and Drug
Administration (FDA) is fluconazole,
which also achieves a high cure rate.(4) Most
of these strains show sensitivity to azole-
based antifungal agents and are therefore
usually responsive to all forms of antifungal
and therapy.(4)
Vulvovaginalis (KVV) Candidiasis therapy
caused by Candida non-albicans for azole
drug administration is recommended for 7-
14 days, except for flukonazole because
7
many non-albicans Candidda are correcting for predisposing factors causing
resistant.(4) In immunocompromised infection.(7)
patients, treatment with conventional
CONCLUSION
antifungal drugs is done with
administration of 7-14 days. (4) Candidiasis is an infection with various
clinical manifestations caused by candida,
EDUCATION
specifically Candida albicans and other
 Avoid or eliminate prediposition yeasts of the genus Candida.(3) Candidiasis
factors.(2) in women is generally the first infection
 Maintain personal hygiene.(2) arising in the vagina called vaginitis and
 If you are overweight, to lose can extend to the vulva (vulvitis) , if both
weight.(2) the vaginal mucosa and vulva are infected,

 To avoid wearing tight pants or they are called candidiasis

underpants.(2) vulvovaginalis.(3)
Caused by vaginal candidiasis 81% by
COMPLICATIONS Candida albicans, 16% by Turolopsus
glabrata, while the other 3%.(5)
If left untreated, candidaemia can cause
Acute and vaginal pruritus (fluor albus) is
metatastic infection focus in the eyes, liver,
an initial complaint, the more common
spleen, CNS, and kidneys. (6) Start early
symptom is vulvar pruritus.(3) Leucorrhoea
treatment to prevent sepsis, abscess
is not always present and often only
formation and death.(6)
slightly.(3) Flour albus in yellowish vaginal
PROGNOSIS candidiasis.(3) Signs the characteristic is
accompanied by clots as a yellowish-white
The prognosis is generally good, especially
milk head.(3)
if the predisposing factor can be
Management Vulvovaginal candidiasis
minimized.(3) Uncomplicated
consists of topical and systemic
Vulvavaginalis (KVV) candidiasis has a
treatment.(4)
good prognosis because generally mild to
DAFTAR PUSTAKA
moderate infections and regarding
immunocompetent patients.(3) In KVV with 1. Sobel JD. Vulvovaginal
frequent complications recurrent infections Candidiasis. In: Holmes KK, editor.
often occur.(7) Therefore proper treatment Sexually Transmitted Diseases. 4th
and prophylactic treatment are needed and ed. New York: Mc Graw Hill;
2008.p. 823 – 35.
8
2. Harnindya, DItta dkk. (2016). Studi 8. Graham, Robin. 2005. Lecture
Retrospektif: Diagnosis dan Notes Dermatologi. Jakarta:
Penatalaksanaan Kandidiasis Erlangga. Hal. 40
Vulvovaginalis. Periodical of
Dermatology and Venereology,
vol.28. https://e-
journal.unair.ac.id/BIKK/article/vie
wFile/2350/1704
3. Djuanda, Adhi. 2011. Ilmu Penyakit
Kulit dan Kelamin. Edisi Ketujuh.
Jakarta: FKUI. Hal. 106-109
4. Katz. Vaginitis.
Katz. Comprehensive Gynecology.
5th ed. Mosby; Elsevier; 2007. 588-
596.
5. Foxman B, Muraglia R, Dietz JP,
Sobel JD, Wagner J. Prevalence of
recurrent vulvovaginal candidiasis
in 5 European countries and the
United States: results from an
internet panel survey. J Low Genit
Tract Dis. 2013 Jul. 17(3):340-5
6. Nyirjesy P. Vulvovaginal
candidiasis and bacterial
vaginosis. Infect Dis Clin North Am.
2008 Dec. 22(4):637-52
7. Cunningham, Leveno, Bloom,
Hauth, Rouse, dan Spong, 2010.
Sexually Transmitted Diseases :
Vaginitis. Dalam : Williams
Obstetrics 23rd Edition. United
States of America : McGraw-Hill
Companies, 1246.