Sandbox: Candida VV

Jump to navigation Jump to search

WikiDoc Resources for Sandbox: Candida VV

Articles

Most recent articles on Sandbox: Candida VV

Most cited articles on Sandbox: Candida VV

Review articles on Sandbox: Candida VV

Articles on Sandbox: Candida VV in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Sandbox: Candida VV

Images of Sandbox: Candida VV

Photos of Sandbox: Candida VV

Podcasts & MP3s on Sandbox: Candida VV

Videos on Sandbox: Candida VV

Evidence Based Medicine

Cochrane Collaboration on Sandbox: Candida VV

Bandolier on Sandbox: Candida VV

TRIP on Sandbox: Candida VV

Clinical Trials

Ongoing Trials on Sandbox: Candida VV at Clinical Trials.gov

Trial results on Sandbox: Candida VV

Clinical Trials on Sandbox: Candida VV at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Sandbox: Candida VV

NICE Guidance on Sandbox: Candida VV

NHS PRODIGY Guidance

FDA on Sandbox: Candida VV

CDC on Sandbox: Candida VV

Books

Books on Sandbox: Candida VV

News

Sandbox: Candida VV in the news

Be alerted to news on Sandbox: Candida VV

News trends on Sandbox: Candida VV

Commentary

Blogs on Sandbox: Candida VV

Definitions

Definitions of Sandbox: Candida VV

Patient Resources / Community

Patient resources on Sandbox: Candida VV

Discussion groups on Sandbox: Candida VV

Patient Handouts on Sandbox: Candida VV

Directions to Hospitals Treating Sandbox: Candida VV

Risk calculators and risk factors for Sandbox: Candida VV

Healthcare Provider Resources

Symptoms of Sandbox: Candida VV

Causes & Risk Factors for Sandbox: Candida VV

Diagnostic studies for Sandbox: Candida VV

Treatment of Sandbox: Candida VV

Continuing Medical Education (CME)

CME Programs on Sandbox: Candida VV

International

Sandbox: Candida VV en Espanol

Sandbox: Candida VV en Francais

Business

Sandbox: Candida VV in the Marketplace

Patents on Sandbox: Candida VV

Experimental / Informatics

List of terms related to Sandbox: Candida VV

To view the Vaginitis main page Click here.
To view the Candidiasis main page Click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and keywords: Vulvovaginal candidiasis, Candidal Vulvovaginitis, Fungal Vaginitis, Yeast infection, Vulvovaginal Candidosis, candida vaginitis, Genital candidiasis

Overview

Candida vulvovagintis is an infection of the vagina and the vestibulum, common in women in the reproductive age group. It is caused by various Candida species with Candida albicans most common pathogen followed by other species like Candida glabarta, Candida krusei etc. Patients present with vulvar pruritus, burning micturition and vaginal discharge.The diagnosis of candidal infection requires a collaboration of clinical and diagnostic findings. Patients have typical white cottage chesee like discharge with hyphae and spores demonstrated on microscopy. Patients with uncomplicated infection respond well to topical and oral azole therapy. 5 to 8% of women develop recurrent vaginitis, which is defined as more than 4 episodes in a year. These patients require a longer duration of therapy with an induction and maintenance phase.

Historical Perspective

  • In 1839, B. Lagenbeck from Germany described a yeast-like fungus for the first time in the human oral infection thrush and its ability to cause it.[1]
  • In 1923 the Candida albicans was described by Christine Marie Berkhout. Over the years the classification of the genera and species has evolved. Obsolete names for this genus include Mycotorula and Torulopsis. The species has also been known in the past as Monilia albicans and Oidium albicans. The current classification is nomen conservandum, which means the name is authorized for use by the International Botanical Congress (IBC).
  • The full current taxonomic classification is available at Candida albicans.
  • The genus Candida includes about 150 different species. However, only a few of those are known to cause human infections. c. albicans is the most significant pathogenic (disease-causing) species. Other Candida species causing diseases in humans include c. tropicalis, c. glabrata, c. krusei, c. parapsilosis, c. dubliniensis, and c. lusitaniae.

Classification

Candida vulvovaginitis can be classified based on the duration of the infection and based on the strain of Candida causing the infection.

Duration

Candida vulvovaginitis can be divided based on the duration and number of episodes of the infection into:[2][3][4][5]

  • Acute, uncomplicated: these are usually sporadic cases of Candida vulvovaginitis, which respond to topical antifungal therapy and have a high cure rate.
  • Acute, complicated: symptoms are more severe than uncomplicated infections and typically require a combination of oral and topical anti-fungal treatment.
  • Recurrent Vulvovaginal Candidiasis (RVVC): defined as 4 or more episodes of Candida vulvovaginitis per year, usually caused by the same strain of Candida. Treatment also requires a combination of oral and topical antifungal agents.
  • According to 2015, Treatment of STD guidelines - Candida vulvovaginitis can be classified into uncomplicated and complicated based on the following features:[6]
Uncomplicated Candida Vulvovaginitis Complicated Candida Vulvovaginitis
  • Sporadic or infrequent VVC
  • Mild-to-moderate VVC
  • Likely to be Candida albicans
  • Non-immunocompromised women

Pathophysiology

Vaginal Defensive mechanisms aganist Candida

Innate Mechanisms

Defense Mechanism of protection Evidence of protection
Vaginal epithelial cells
  • Protective role in vivo unknown
  • Patients with recurrent candida infections have decreased anti-Candida activity
Mannose-binding lectin
Activated lactoferrin[10]
  • Fungistatic and fungicidal activity
  • Role in protection aganist infection is not clear
Vaginal bacterial flora
  • Role in protection aganist vaginitis still unclear
Phagocytic systems/polymononuclear leukocytes, mononuclear cells, complement
  • Role in protection still unclear

Adaptive Mechanisms

Defense Mechanism Role in Protection
Immunoglobulin mediated immunity Systemic IgM, IgG, and local IgA antibodies are produced in response to the infection[12]
  • Protective role not proven.
  • Elevated titres of vaginal anti-Candida IgG, IgA are detected in women with recurrent vaginitis
  • Persistent symptoms could be attributed to anti-Candida IgE[13]
Cell Mediated Immunity

Interleukin 4 (Th2) inhibits anti-Candida activity of nitric oxide and protective pro-inflammatory Th1 cytokines.[14]

  • Role in protection from vulvovaginitis is still not clear
  • It is still a hypothesis[15]
  • Patients with recurrent infection have undetectable Th2 cytokines.

Candida Virulence Factors

Pathogenesis

Genetics

Gross Pathology

On speculum examination typical curdy white discharge is present.

Microscopic Pathology

Microscopic examination of the wet mount with 10% KOH or saline demonstrates hyphae, pseudohyphae and blastospores.

Associated Conditions

Causes

Candida vulvovaginitis is caused by many different species of Candida. They are divided into Candida albicans and Candida non-albicans species based on the causative pathogen:

Common Causes

Less Common Causes

These are less commonly isolated in patients but is important to identify the species as they are less sensitive to standard azole therapy and cause recurrent infection.[31][32]

Differentiating Candida Vulvovaginitis from other Diseases

Candida Vulvovaginitis must be differentiated from the following diseases which have a similar presentation:[35][36][37][38][39]

Disease Findings
Trichomoniasis
Atrophic vaginitis
Desquamative inflammatory vaginitis
  • Chronic clinical syndrome with unknown etiology
  • Presents with dyspareunia, dyspareunia, yellow, grey, or green profuse vaginal discharge with the signs of vaginal inflammation and elevated vaginal pH (>4.5)
  • Microscopy shows large number of parabasal (immature squamous epithelial cells) and inflammatory cells
Bacterial Vaginosis

Epidemiology and Demographics

Age

  • Incidence of Candida vulvovaginitis is higher in pregnant women.[41][42]
  • Women in reproductive age group are prone for Candida vulvovaginits and at least one episode is reported in 70 to 75% in this population group.[43]
  • 40 to 50% of patients with a prior yeast infection have multiple episodes of yeast infection.[41]
  • Among the adult population 5 to 8% women have more than four episodes of infection.[44]
  • In 20% asymptomatic healthy adolescent women, Candida species can be isolated from the vagina.[45]

Race

Candida vulvovaginitis is more prevalent among African American women than white American women.[44]

Risk Factors

The following risk factors have been implicated in predisposing patients to Candida vulvovaginitis:

Risk Factors for Recurrent Candida Vulvovaginitis[53]

Microbial Factors Genetic Factors Host Behavioural Factors Other Risk Factors
  • Lewis blood group non-secretor status
  • African American race
  • Familial history of recurrent Candida vulvovaginitis

Table adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71[4]

Screening

There are no screening procedures for Candida vulvovaginitis.

Natural History, Complications and Prognosis

Natural History

Candida vulvovaginitis is a common infection of women in reproductive age group. Patients present with vulvar pruritus, dysuria, and vaginal discharge. Half of the affected patients have multiple episodes of the infection and less than 10% have recurrent infection.[55]

Prognosis

Candida albicans vulvovaginitis has excellent prognosis with azole therapy. Patients with non-Candida albicans infections are prone to have recurrence and treatment with boric acid and oral fluconazole has good prognosis.[56]

Complications

Candida vulvovaginitis is a self limiting disease with no complications.

Diagnosis

Diagnosis of Candida vulvovaginitis requires a correlation of clinical features, microscopic examination, and vaginal culture.

History and Symptoms

Symptoms of vulvovaginitis caused by Candida species are indistinguishable and include the following:[57][2][3]

  • Pruritus is the most significant symptom
  • Change in the amount and the color of vaginal discharge: It is characterized by a thick, white "cottage cheese-like" vaginal discharge
  • Pain on urination (dysuria)
  • Pain on sexual intercourse (dyspareunia)
  • Vulvovaginal soreness
  • Symptoms aggravate a week before the menses

Physical Examination

Candida vulvovaginitis requires a careful examination of the external genitalia, the vaginal sidewalls and the cervix. Signs include:[58][2]

Laboratory Findings

The laboratory findings consistent with the diagnosis of Candida vulvovaginitis include:[2][59][4]

Approach to patient with Candida Vulvovaginitis

The following is a algorithm for diagnosis and treatment of vulvovaginal candidiasis :

 
 
 
 
 
Symptomatic Vaginitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Whitish discharge adherent to the vaginal walls, excoriations and fissures in the genital area
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform direct microscopy of the vaginal discharge with saline or 10% KOH
Estimate pH of vaginal discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative direct microscopy
pH < 4.5
 
 
 
 
Positive direct microscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Send for culture
Consider azole therapy
 
 
 
 
No culture necessary
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
pH < 4.5
No excess WBC's
 
 
pH > 4.5
Excess WBC's
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start azole therapy
 
 
Consider mixed infection

Algorithm adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71[4]

Treatment

Medical Therapy

According to, 2016 Update by the Infectious Diseases Society of America medical therapy for Candida vulvovaginitis includes[60]:

  • Uncomplicated Candida Vulvovaginits:
    • 1st line :Any topical antifungal agents can be used and all of them have equal efficacy
    • Alternative : Single 150mg dose of oral fluconazole is recommended
  • Severe acute Candida vulvovaginitis:
    • 1st line: Oral fluconazole 150mg, given every 72 hours for a total of 2 or 3 doses
  • Candida glabrata: When unresponsive to oral azoles
    • 1st line: Topical intravaginal boric acid administered in a gelatin capsule, 600mg daily for 14 days
    • 2nd line: Nystatin intravaginal suppositories, 100,000 units daily for 14 days
    • 3rd line: Topical 17% flucytosine cream alone or in combination with amphotericin B cream daily for 14 days
  • Recurring vulvovaginal candidiasis:
    • 1st line: 10 to 14 days of induction therapy with a topical agent or oral fluconazole, followed by fluconazole, 150mg weekly for 6 months

Candida Vulvovaginitis in HIV positive women

  • Treatment of symptomatic Candida vulvovaginitis in HIV-positive women is similar to HIV-negative individuals.

Surgical Therapy

There are no surgical options for Candida vulvovaginitis.

Prevention

Primary Prevention

  • There are no primary preventive measures for Candidal infection.

Secondary Prevention

Gallery

Image: Candidiasis 17.jpeg| Candidiasis of the fingernail caused by a fungus of the genus Candida. From Public Health Image Library (PHIL). [61]

Skin folds

Genitourinary

Oral cavity

References

  1. Barnett JA (2008). "A history of research on yeasts 12: medical yeasts part 1, Candida albicans". Yeast. 25 (6): 385–417. doi:10.1002/yea.1595. PMID 18509848.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Eckert LO (2006). "Clinical practice. Acute vulvovaginitis". N. Engl. J. Med. 355 (12): 1244–52. doi:10.1056/NEJMcp053720. PMID 16990387.
  3. 3.0 3.1 3.2 Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR (1998). "Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations". Am. J. Obstet. Gynecol. 178 (2): 203–11. PMID 9500475.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Sobel JD (2007). "Vulvovaginal candidosis". Lancet. 369 (9577): 1961–71. doi:10.1016/S0140-6736(07)60917-9. PMID 17560449.
  5. Vazquez JA, Sobel JD, Demitriou R, Vaishampayan J, Lynch M, Zervos MJ (1994). "Karyotyping of Candida albicans isolates obtained longitudinally in women with recurrent vulvovaginal candidiasis". J. Infect. Dis. 170 (6): 1566–9. PMID 7995997.
  6. Workowski KA (2015). "Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines". Clin Infect Dis. 61 Suppl 8: S759–62. doi:10.1093/cid/civ771. PMID 26602614.
  7. Barousse MM, Espinosa T, Dunlap K, Fidel PL (2005). "Vaginal epithelial cell anti-Candida albicans activity is associated with protection against symptomatic vaginal candidiasis". Infect Immun. 73 (11): 7765–7. doi:10.1128/IAI.73.11.7765-7767.2005. PMC 1273905. PMID 16239581.
  8. 8.0 8.1 Donders GG, Babula O, Bellen G, Linhares IM, Witkin SS (2008). "Mannose-binding lectin gene polymorphism and resistance to therapy in women with recurrent vulvovaginal candidiasis". BJOG. 115 (10): 1225–31. doi:10.1111/j.1471-0528.2008.01830.x. PMID 18715406.
  9. Ip WK, Lau YL (2004). "Role of mannose-binding lectin in the innate defense against Candida albicans: enhancement of complement activation, but lack of opsonic function, in [[phagocytosis]] by human dendritic cells". J Infect Dis. 190 (3): 632–40. doi:10.1086/422397. PMID 15243942. URL–wikilink conflict (help)
  10. Naidu AS, Chen J, Martinez C, Tulpinski J, Pal BK, Fowler RS (2004). "Activated lactoferrin's ability to inhibit Candida growth and block yeast adhesion to the vaginal epithelial monolayer". J Reprod Med. 49 (11): 859–66. PMID 15603095.
  11. Diamond RD, Krzesicki R, Jao W (1978). "Damage to pseudohyphal forms of Candida albicans by neutrophils in the absence of serum in vitro". J Clin Invest. 61 (2): 349–59. doi:10.1172/JCI108945. PMC 372545. PMID 340470.
  12. Waldman RH, Cruz JM, Rowe DS (1972). "Immunoglobulin levels and antibody to Candida albicans in human cervicovaginal secretions". Clin Exp Immunol. 10 (3): 427–34. PMC 1713147. PMID 4556009.
  13. Fidel PL, Sobel JD (1996). "Immunopathogenesis of recurrent vulvovaginal candidiasis". Clin Microbiol Rev. 9 (3): 335–48. PMC 172897. PMID 8809464.
  14. Fidel PL (2005). "Immunity in vaginal candidiasis". Curr Opin Infect Dis. 18 (2): 107–11. PMID 15735412.
  15. Fidel PL, Barousse M, Espinosa T, Ficarra M, Sturtevant J, Martin DH; et al. (2004). "An intravaginal live Candida challenge in humans leads to new hypotheses for the immunopathogenesis of vulvovaginal candidiasis". Infect Immun. 72 (5): 2939–46. PMC 387876. PMID 15102806.
  16. 16.0 16.1 16.2 Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
  17. Sobel JD, Muller G, Buckley HR (1984). "Critical role of germ tube formation in the pathogenesis of candidal vaginitis". Infect Immun. 44 (3): 576–80. PMC 263631. PMID 6327527.
  18. 18.0 18.1 Sobel JD (1989). "Pathogenesis of Candida vulvovaginitis". Curr Top Med Mycol. 3: 86–108. PMID 2688924.
  19. Schaller M, Bein M, Korting HC, Baur S, Hamm G, Monod M; et al. (2003). "The secreted aspartyl proteinases Sap1 and Sap2 cause tissue damage in an in vitro model of vaginal candidiasis based on reconstituted human vaginal epithelium". Infect Immun. 71 (6): 3227–34. PMC 155757. PMID 12761103.
  20. Soll DR (1988). "High-frequency switching in Candida albicans and its relations to vaginal candidiasis". Am J Obstet Gynecol. 158 (4): 997–1001. PMID 3284370.
  21. Muzny CA, Schwebke JR (2015). "Biofilms: An Underappreciated Mechanism of Treatment Failure and Recurrence in Vaginal Infections". Clin Infect Dis. 61 (4): 601–6. doi:10.1093/cid/civ353. PMC 4607736. PMID 25935553.
  22. Dennerstein GJ, Ellis DH (2001). "Oestrogen, glycogen and vaginal candidiasis". Aust N Z J Obstet Gynaecol. 41 (3): 326–8. PMID 11592551.
  23. Miles MR, Olsen L, Rogers A (1977). "Recurrent vaginal candidiasis. Importance of an intestinal reservoir". JAMA. 238 (17): 1836–7. PMID 333134.
  24. Fidel PL, Vazquez JA, Sobel JD (1999). "Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans". Clin Microbiol Rev. 12 (1): 80–96. PMC 88907. PMID 9880475.
  25. Calderon L, Williams R, Martinez M, Clemons KV, Stevens DA (2003). "Genetic susceptibility to vaginal candidiasis". Med Mycol. 41 (2): 143–7. PMID 12964847.
  26. Liu F, Liao Q, Liu Z (2006). "Mannose-binding lectin and vulvovaginal candidiasis". Int J Gynaecol Obstet. 92 (1): 43–7. doi:10.1016/j.ijgo.2005.08.024. PMID 16256117.
  27. Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE (2013). "Mixed vaginitis-more than coinfection and with therapeutic implications". Curr Infect Dis Rep. 15 (2): 104–8. doi:10.1007/s11908-013-0325-5. PMID 23354954.
  28. Anderson MR, Klink K, Cohrssen A (2004). "Evaluation of vaginal complaints". JAMA. 291 (11): 1368–79. doi:10.1001/jama.291.11.1368. PMID 15026404.
  29. Corsello S, Spinillo A, Osnengo G, Penna C, Guaschino S, Beltrame A; et al. (2003). "An epidemiological survey of vulvovaginal candidiasis in Italy". Eur J Obstet Gynecol Reprod Biol. 110 (1): 66–72. PMID 12932875.
  30. Okungbowa FI, Isikhuemhen OS, Dede AP (2003). "The distribution frequency of Candida species in the genitourinary tract among symptomatic individuals in Nigerian cities". Rev Iberoam Micol. 20 (2): 60–3. PMID 15456373.
  31. Bauters TG, Dhont MA, Temmerman MI, Nelis HJ (2002). "Prevalence of vulvovaginal candidiasis and susceptibility to fluconazole in women". Am J Obstet Gynecol. 187 (3): 569–74. PMID 12237629.
  32. Holland J, Young ML, Lee O, C-A Chen S (2003). "Vulvovaginal carriage of yeasts other than Candida albicans". Sex Transm Infect. 79 (3): 249–50. PMC 1744683. PMID 12794215.
  33. Nyirjesy P, Alexander AB, Weitz MV (2005). "Vaginal Candida parapsilosis: pathogen or bystander?". Infect Dis Obstet Gynecol. 13 (1): 37–41. doi:10.1080/10647440400025603. PMC 1784559. PMID 16040326.
  34. Singh S, Sobel JD, Bhargava P, Boikov D, Vazquez JA (2002). "Vaginitis due to Candida krusei: epidemiology, clinical aspects, and therapy". Clin Infect Dis. 35 (9): 1066–70. doi:10.1086/343826. PMID 12384840.
  35. Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016
  36. Bachmann GA, Nevadunsky NS (2000). "Diagnosis and treatment of atrophic vaginitis". Am Fam Physician. 61 (10): 3090–6. PMID 10839558.
  37. Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB; et al. (1988). "Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens". JAMA. 259 (8): 1223–7. PMID 2448502.
  38. Sobel JD, Reichman O, Misra D, Yoo W (2011). "Prognosis and treatment of desquamative inflammatory vaginitis". Obstet Gynecol. 117 (4): 850–5. doi:10.1097/AOG.0b013e3182117c9e. PMID 21422855.
  39. Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
  40. Allsworth JE, Peipert JF (2007). "Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data". Obstet Gynecol. 109 (1): 114–20. doi:10.1097/01.AOG.0000247627.84791.91. PMID 17197596.
  41. 41.0 41.1 Hurley R, De Louvois J (1979). "Candida vaginitis". Postgrad Med J. 55 (647): 645–7. PMC 2425644. PMID 523355.
  42. García Heredia M, García SD, Copolillo EF, Cora Eliseth M, Barata AD, Vay CA; et al. (2006). "[Prevalence of vaginal candidiasis in pregnant women. Identification of yeasts and susceptibility to antifungal agents]". Rev Argent Microbiol. 38 (1): 9–12. PMID 16784126.
  43. Zuckerman, Andrea; Romano, Mary (2016). "Clinical Recommendation: Vulvovaginitis". Journal of Pediatric and AdolescentGynecology. 29 (6): 673–679. doi:10.1016/j.jpag.2016.08.002. ISSN 1083-3188.
  44. 44.0 44.1 Foxman B, Marsh JV, Gillespie B, Sobel JD (1998). "Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey". J Womens Health. 7 (9): 1167–74. PMID 9861594.
  45. Barousse, M M (2004). "Vaginal yeast colonisation, prevalence of vaginitis, and associated local immunity in adolescents". Sexually Transmitted Infections. 80 (1): 48–53. doi:10.1136/sti.2002.003855. ISSN 1368-4973.
  46. Foxman B (1990). "The epidemiology of vulvovaginal candidiasis: risk factors". Am J Public Health. 80 (3): 329–31. PMC 1404680. PMID 2305918.
  47. Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
  48. Wilton L, Kollarova M, Heeley E, Shakir S (2003). "Relative risk of vaginal candidiasis after use of antibiotics compared with antidepressants in women: postmarketing surveillance data in England". Drug Saf. 26 (8): 589–97. PMID 12825971.
  49. de Leon EM, Jacober SJ, Sobel JD, Foxman B (2002). "Prevalence and risk factors for vaginal Candida colonization in women with type 1 and type 2 diabetes". BMC Infect. Dis. 2: 1. PMC 65518. PMID 11835694.
  50. Donders GG (2002). "Lower Genital Tract Infections in Diabetic Women". Curr Infect Dis Rep. 4 (6): 536–539. PMID 12433331.
  51. Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, Sobel JD (2003). "Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity". Obstet Gynecol. 101 (3): 548–56. PMID 12636961.
  52. Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
  53. Sobel JD (2016). "Recurrent vulvovaginal candidiasis". Am J Obstet Gynecol. 214 (1): 15–21. doi:10.1016/j.ajog.2015.06.067. PMID 26164695.
  54. Reed BD, Zazove P, Pierson CL, Gorenflo DW, Horrocks J (2003). "Candida transmission and sexual behaviors as risks for a repeat episode of Candida vulvovaginitis". J Womens Health (Larchmt). 12 (10): 979–89. doi:10.1089/154099903322643901. PMID 14709186.
  55. Fidel PL, Vazquez JA, Sobel JD (1999). "Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans". Clin Microbiol Rev. 12 (1): 80–96. PMC 88907. PMID 9880475.
  56. Fidel PL, Vazquez JA, Sobel JD (1999). "Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans". Clin Microbiol Rev. 12 (1): 80–96. PMC 88907. PMID 9880475.
  57. Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
  58. Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
  59. Mendling W, Brasch J (2012). "Guideline vulvovaginal candidosis (2010) of the German Society for Gynecology and Obstetrics, the Working Group for Infections and Infectimmunology in Gynecology and Obstetrics, the German Society of Dermatology, the Board of German Dermatologists and the German Speaking Mycological Society". Mycoses. 55 Suppl 3: 1–13. doi:10.1111/j.1439-0507.2012.02185.x. PMID 22519657.
  60. Pappas, Peter G.; Kauffman, Carol A.; Andes, David R.; Clancy, Cornelius J.; Marr, Kieren A.; Ostrosky-Zeichner, Luis; Reboli, Annette C.; Schuster, Mindy G.; Vazquez, Jose A.; Walsh, Thomas J.; Zaoutis, Theoklis E.; Sobel, Jack D. (2015). "Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America". Clinical Infectious Diseases: civ933. doi:10.1093/cid/civ933. ISSN 1058-4838.
  61. 61.0 61.1 61.2 "Public Health Image Library (PHIL)".
  62. 62.0 62.1 62.2 62.3 62.4 62.5 62.6 62.7 62.8 "Dermatology Atlas".