Antifungals
The antifungal agents used to treat vaginitis are imidazole derivatives that exert a fungicidal effect by altering permeability of the fungal cell membrane. The mechanism of action also may involve alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to fungal cell.
Intravaginal and topical therapy with a variety of antifungals (eg, clotrimazole, miconazole, terconazole, tioconazole) is highly effective. Many of these preparations are now available over the counter. Various 1-, 3-, and 7-day regimens may be used. Cure rates of 90% are reported with longer courses.
The oral triterpenoid agent, ibrexafungerp, is the first non-azole antifungal approved for vulvovaginal candidiasis (VVC) and the first drug approved in a new antifungal class for VVC in more than 20 years.
Fluconazole (Diflucan)
Fluconazole is a synthetic PO antifungal agent (a broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. Whereas ease of use should be considered, direct cost may be a limiting factor. PO antifungals should not be recommended in pregnancy. Current recommendations are for a 7-day course of antifungal topical therapy.
Ibrexafungerp (Brexafemme)
Inhibits glucan synthase, an enzyme involved in the formation of 1,3-beta-D-glucan, an essential component of the fungal cell wall. It is indicated for vulvovaginal candidiasis (VVC) in adult and postmenarchal females.
Miconazole vaginal (Monistat-7, Monistat-1)
Miconazole damages the fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death. Metabolism occurs in the liver. Recurrent infections usually are treated with intravaginal regimens for 10-14 days, followed by maintenance oral treatment for 6 months. Dual Pak is not for use in children.
Clotrimazole (Gyne-Lotrimin-3, Gyne-Lotrimin-7)
Clotrimazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells. The recommended duration of intravaginal therapy is generally 3-7 days.
Terconazole (Terazol 7, Terazol 3)
Terconazole damages the fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death.
Tioconazole (Vagistat 1, 1-Day)
Tioconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells.
Butoconazole (Gynazole-1)
Butoconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells. It is effective only for vaginitis caused by candidal organisms.
Nystatin vaginal
Nystatin is a fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. It is effective against various yeasts and yeastlike fungi. It changes the permeability of the fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.
Ketoconazole (Nizoral)
Ketoconazole is an imidazole broad-spectrum antifungal agent. It inhibits synthesis of ergosterol, causing cellular components to leak, which results in fungal cell death. Ketoconazole is generally used as maintenance therapy for recurrent vulvovaginal candidiasis
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(A) Two trophozoites of Trichomonas vaginalis obtained from in vitro culture, stained with Giemsa. (B) Trophozoite of T vaginalis in vaginal smear, stained with Giemsa. Images courtesy of Centers for Disease Control and Prevention.
