Consensus on Management of Dermatophytosis and Vulvovaginal Infections in Non- Pregnant and Pregnant Females
Journal of Gynecology and Obstetrics
Volume 8, Issue 6, November 2020, Pages: 195-210
Received: Nov. 11, 2020;
Accepted: Nov. 25, 2020;
Published: Dec. 16, 2020
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Sanjiv Kandhari, Dr. Kandhari’s Skin and Dental Clinic, New Delhi, India
Piyush Prabhat, Jeevak Hospital, Mumbai, India
Madhu Rengarajan, Department of Dermatology, Venereology and Leprosy, Madras Medical College, Chennai, India
Sunil Dogra, Department of Dermatology, Venereology & Leprology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
Chitra Nayak, Department of Dermatology, Topiwala National Medical College & BYL Nair Hospital, Mumbai, India
Dibyendu Banerjee, Department of Obstetrics & Gynecology, Charnock Hospital, Kolkata, India
Jayashree Sridhar, KRG’s Blessed Mom Clinic, Indore, India
Mukesh Patil, Dr. Mukesh Patil’s Center for Women’s Health, Vasai-Virar, India
Neena Singh, Fortis La Femme Hospital, New Delhi, India
Pondicherry Gopinath, Department of OBGY and IVF, SRM Institute of Medical Sciences, Chennai, India
Ratna Talukdar, Department of Obstetrics & Gynecology, Gauhati Medical College, Guwahati, India
Vishalakshi Viswanath, Department of Dermatology, Rajiv Gandhi Medical College & CSMH, Thane, India
There has been an increasing prevalence of dermatophytosis among the females in India, over the last 5-6 years. Similarly an increase in the occurrence of vulvovaginal infections has also been observed. The recommendations from existing guidelines do not focus on these infections in females and provide optimal outcomes in real world setting. Hence, the aim of the present consensus was to formulate recommendations based on current clinical experience to address these infections. A multispecialty panel of 12 members consisting of 7 gynecologists and 5 dermatologists participated in the pursuit of obtaining consensus by modified Delphi process. All the panelists formulated questionnaire after critical review of literature. Four rounds of questionnaires containing a total of 63 questions were floated through Google docs survey and responses were marked by all the panelists. Agreement for a given question/statement as ≥75% was set to achieve consensus. Out of the 63 questions/statements, consensus was obtained on diagnosis and treatment of dermatophytosis and VVI in non-pregnant and pregnant females, in 61 statements. The panel also formulated treatment algorithm for dermatophytosis and VVI. The present consensus will provide a guidance to the clinicians in India regarding management of dermatophytosis and VVI in pregnant and non-pregnant females in the current scenario of therapeutic challenges in both the infections.
Consensus on Management of Dermatophytosis and Vulvovaginal Infections in Non- Pregnant and Pregnant Females, Journal of Gynecology and Obstetrics.
Vol. 8, No. 6,
2020, pp. 195-210.
White F, Findley K, Dawson T, Scheynius A, Boekhout T, Cuomo C, et al. Fungi on the Skin: Dermatophytes and Malassezia. Cold Spring Harb Perspect Med 2014; 4: a019802.
Panda S, Verma S. The menace of dermatophytosis in India. The evidence that we need. Indian J Dermatol Venereol Leprol 2017; 83: 281-4.
Narang T, Bhattacharjee R, Singh S, Jha K, Kavita, Mahajan R, Dogra S. Quality of life and psychological morbidity in patients with superficial cutaneous dermatophytosis. Mycoses 2019; 62 (8): 680-685.
Bishnoi A, Vinay K, Dogra S. Emergence of recalcitrant dermatophytosis in India. Lancet Infect Dis 2018; 18 (3): 250-251.
Dogra S, Uprety S. The menace of chronic and recurrent dermatophytosis in India: Is the problem deeper than we perceive? Indian Dermatol Online J 2016; 7 (2): 73-6.
Verma S, Madhu R. The great Indian epidemic of superficial dermatophytosis: An appraisal. Indian J Dermatol 2017; 62: 227-36.
Verma S, Vasani R, Gupta S. Involvement of little discussed anatomical locations in superficial dermatophytosis sundry observations and musings. Indian Dermatol Online J 2020; 11: 419-24.
Mullick J, Majumdar T, Ray J, Sil S. Changing Trends of Candida Isolates and their Antifungal Susceptibility Pattern in Vulvovaginal Candidiasis Cases of Tripura, North East India. Journal of Evolution of Medical and Dental Sciences 2015; 4 (94): 15918-15922.
Shaw D, Singh S, Dogra S, Jayaraman J, Bhat R, Panda S, et al. Minimal inhibitory concentration and upper limit of wild type distribution for 13 antifungal agents against Trichophyton mentagrophytes/interdigitale complex of Indian origin. Antimicrob Agents Chemother 2020. pii: AAC. 01964-19.
Rajagopalan M, Inamadar A, Mittal A, Miskeen A, Srinivas C, Sardana K, et al. Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). BMC Dermatol 2018; 18 (6): 1-11.
Soman R, Balaji V, Ashit H, Prakash J, Yatin M, Vasant N, et al. Indian consensus on the management of CRE infection in critically ill patients (ICONIC) — India, Expert Rev Anti Infect Ther 2019; 17 (8): 647-660.
Lema VM. Recurrent Vulvo-Vaginal Candidiasis: Diagnostic and Management Challenges in a Developing Country Context. Obstet Gynecol Int J 2017; 7 (5): 00260.
Wilson J. Managing recurrent bacterial vaginosis. Sex Transm Infect 2004; 80 (1): 8–11.
2015 Sexually Transmitted Diseases Treatment Guidelines. [Internet] June 2015. [Cited 10 February 2020]. Available from https://www.cdc.gov/std/tg2015/candidiasis.html.
Rudramurthy SM, Shaw D. Overview and update on the laboratory diagnosis of dermatophytosis. Clin Dermatol Rev 2018; 2: 1-10.
Pihet M, Le Govic Y. Reappraisal of conventional diagnosis for dermatophytes. Mycopathologia 2017; 182 (1–2): 169–80.
Sahoo AK, Mahajan R. Management of tinea corporis, tinea cruris, and tinea pedis: A comprehensive review. Indian Dermatol Online J 2016; 7: 77-86.
Rotta I, Ziegelmann PK, Otuki MF, Riveros BS, Bernardo NL, Correr CJ. Efficacy of topical antifungals in the treatment of dermatophytosis: a mixed treatment comparison meta-analysis involving 14 treatments. JAMA Dermatol 2013; 149: 341–9.
El-Gohary M, van Zuuren EJ, Fedorowicz Z, Burgess H, Doney L, Stuart B, et al. Topical antifungal treatments for tinea cruris and tinea corporis. Cochrane Database Syst Rev 2014; 8: CD009992.
Weitzman I, Summerbell R. The dermatophytes. Clin Microbiol Rev 1995; 8 (2): 240-259.
Gupta AK, Deagle D. A critical appraisal of once-daily topical luliconazole for the treatment of superficial fungal infections. Infect Drug Resist 2016; 9: 1-6.
Carrillo-Muñoz A, Tur-Tur C, Cárdenes D, Estivill D, Giusiano G. Sertaconazole Nitrate Shows Fungicidal and Fungistatic Activities against Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum, Causative Agents of Tinea Pedis. Antimicrob Agents Chemother 2011 Sep; 55 (9): 4420–4421.
Moodahadu-Bangera L, Martis J, Mittal R, Krishnankutty B, Kumar N, Bellary S, et al. Eberconazole - Pharmacological and clinical review. Indian J Dermatol Venereol Leprol 2012; 78: 217-22.
Veraldi S, Milano R. Topical Fenticonazole in Dermatology and Gynaecology: Current Role in Therapy. Drugs 2008; 68 (15): 2183-2194.
Poojary SA. Topical antifungals: A review and their role in current management of dermatophytoses. Clin Dermatol Rev. 2017; 1 (S1): 24-9.
Rosen T, Schell B, Orengo I. Anti-inflammatory Activity of Antifungal Preparations. Int J Dermatol. 1997; 36 (10): 788-92.
Rengasamy M, Chellam J, Ganapati S. Systemic therapy of dermatophytosis: Practical and systematic approach. Clin Dermatol Rev 2017; 1: S19-23.
Bourlond A, Lachapelle JM, Aussems J, Boyden B, Campaert H, Conincx S, et al. Double-blind comparison of Itraconazole with Griseofulvin in the treatment of tinea Corporis and tinea Cruris. Int J Dermatol 1989; 28 (6): 410–2.
Saoji V, Madke B. Efficacy of salicylic acid peel in dermatophytosis. Indian J Dermatol Venereol Leprol 2019. doi: 10.4103/ijdvl.IJDVL_853_18. [Epub ahead of print]
Shivanna R, Inamadar AC. Clinical failure of antifungal therapy of dermatophytoses: Recurrence, resistance, and remedy. Indian J Drugs Dermatol 2017; 3: 1-3.
Pai V, Ganavalli A, Kikkeri NN. Antifungal resistance in dermatology. Indian J Dermatol 2018; 63: 361-8.
Kanafani ZA, Perfect JR. Antimicrobial resistance: Resistance to antifungal agents: Mechanisms and clinical impact. Clin Infect Dis 2008; 46: 120-8.
Pathania S, Rudramurthy SM, Narang T, Saikia UN, Dogra S. A prospective study of the epidemiological and clinical patterns of recurrent dermatophytosis at a tertiary care hospital in India. Indian J Dermatol Venereol Leprol 2018; 84 (6): 678-684.
Chaudhary RG, Rathod SP, Jagati A, Baxi K, Ambasana A, Patel D. Prescription and usage pattern of topical corticosteroids among out-patient attendees with dermatophyte infections and its analysis: A cross-sectional, survey-based study. Indian Dermatol Online J 2019; 10: 279-83.
Havlickova B, Friedrich M. The advantages of topical combination therapy in the treatment of inflammatory dermatomycoses. Mycoses 2008; 51 (4): 16-26.
Solomon BA, Glass AT, Rabbin PE. Tinea incognito and “over-the-counter” potent topical steroids. Cutis 1996; 58: 295–6.
Dutta B, Rasul ES, Boro B. Clinico-epidemiological study of tinea incognito with microbiological correlation. Indian J Dermatol Venereol Leprol 2017; 83: 326–31.
Nakka A, Bommakanti J, Karumuri S, Thambisetti N. Evaluation of newer imidazoles in dermatophytosis. Int J Res Dermatol 2020; 6: 75-9.
Jensen JM, Pfeiffer S, Akaki T, Schröder JM, Kleine M, Neumann C, et al. Barrier function, epidermal differentiation, and human beta-defensin 2 expression in tinea corporis. J Invest Dermatol 2007; 127 (7): 1720–7.
Kaul S, Yadav S, Dogra S. Treatment of dermatophytosis in elderly, children, and pregnant women. Indian Dermatol Online J 2017; 8: 310-8.
Prabhu SS, Sankineni P. Managing dermatophytoses in pregnancy, lactation, and children. Clin Dermatol Rev 2017; 1: S34-7.
Denning D, Kneale M, Sobel J, Rautemma-Richardson R. Global burden of recurrent vulvovaginal candidiasis: a systematic review. Lancet Infect Dis 2018; 18: e339–47.
Ribeiro M, Dietze R, Paula C, Da Matta D, Colombo A. Susceptibility profile of vaginal yeast isolates from Brazil. Mycopathologia 2001, 151, 5–10.
Ozcan S, Budak F, Yucesoy G, Susever S, Willke A. Prevalence, susceptibility profile and proteinase production of yeasts causing vulvovaginitis in Turkish women. APMIS 2006; 114: 139–145.
Ahmad A, Khan A. Prevalence of Candida species and potential risk factors for vulvovaginal candidiasis in Aligarh, India. Eur J Obstet Gynecol Reprod Biol 2009; 144: 68–71.
Kumari V, Banerjee T, Kumar P, Pandey S, Tilak R. Emergence of non-albicans Candida among candida vulvovaginitis cases and study of their potential virulence factors, from a tertiary care center, North India. Indian J Pathol Microbiol 2013; 56: 144–147.
Edwards L. The diagnosis and treatment of infectious vaginitis. Dermatol Ther 2004; 17 (1): 102-110.
El-Din S, Reynolds M, Ashbee H, Barton R, Evans E. An investigation into the pathogenesis of vulvo-vaginal candidosis. Sex Transm Inf 2001; 77: 179-183.
Kalia N, Singh J, Sharma S, Kamboj S, Arora H, Kaur M. Prevalence of Vulvovaginal Infections and Species Specific Distribution of Vulvovaginal Candidiasis in Married Women of North India. Int J Curr Microbiol App Sci 2015; 4 (8): 253-266.
Investigation and management of vaginal discharge in adult women. [Internet] December 2014. [Cited 10 February 2020]. Available from https://www.ouh.nhs.uk/microbiology/diagnostic-tests/atoz/documents/discharge.pdf.
Matheson A, Mazza D. Recurrent vulvovaginal candidiasis: A review of guideline recommendations. Aust N Z J Obstet Gynaecol 2017; 1–7.
Pappas P, Kauffman C, Andes D, Clancy C, Marr K, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62 (4): e1-50.
Deorukhkar S. Changing Trends in Epidemiology of Candidiasis and Role of Non-Albicans Candida Species. Adv Tech Clin Microbiol 2016; 1 (1): 1-2.
Makanjuola O, Bongomin F, Fayemiwo S. An Update on the Roles of Non-albicans Candida Species in Vulvovaginitis. J Fungi (Basel) 2018; 4 (4): 121.
Uchida K, Abe S, Yamaguchi H. The Postantifungal Effect (PAFE) of Itraconazole, in Comparison with Those of Miconazole and Fluconazole, on Candida Species. Microbiol Immunol 2006; 50 (9), 679–685.
2015 Sexually Transmitted Diseases Treatment Guidelines. [Internet] June 2015. [Cited 10 February 2020]. Available from https://www.cdc.gov/std/tg2015/bv.html.
Menard JP. Antibacterial treatment of bacterial vaginosis: current and emerging therapies. International Journal of Women’s Health 2011: 3 295–305.
Pharmacia and Upjohn Company LLC. Cleocin HCL (clindamycin hydrochloride capsules). [package insert]. U.S. Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/050162s092s093lbl.pdf. Revised March 2020. Accessed April 2020.
Pharmacia and Upjohn Company LLC. Cleocin (clindamycin phosphate vaginal cream). [package insert]. U.S. Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/050680s010,050767s011lbl.pdf. Revised March 2020. Accessed April 2020.
GD Searle LLC. Flagyl (metronidazole tablets). [package insert]. U.S. Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/012623s061lbl.pdf. Revised April 2018. Accessed February 2020.
Teva Pharms. Vandazole (metronidazole vaginal gel). [package insert]. U.S. Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_docs/label/2005/021806lbl.pdf. Revised August 2019. Accessed January 2020.
Leyva-Gómez G, Prado-Audelo M, Ortega-Peña S, Mendoza-Muñoz N, Urbán-Morlán Z, González-Torres M, et al. Modifications in Vaginal Microbiota and Their Influence on Drug Release: Challenges and Opportunities. Pharmaceutics 2019; 11 (5). pii: E217.
Sobel S, Chaim W. Vaginal Microbiology of Women with Acute Recurrent Vulvovaginal Candidiasis. Journal of Clinical Microbiology 1996 34 (10): 2497–2499.
Homayouni A, Bastani P, Ziyadi S, Mohammad-Alizadeh-Charandabi S, Ghalibaf M, Mortazavian A, et al. Effects of probiotics on the recurrence of bacterial vaginosis: a review. J Low Genit Tract Dis 2014; 18 (1): 79-86.
Heczko P, Tomusiak A, Adamski P, Jakimiuk A, Stefanski G, Mikolajczyk-Cichonska A, et al. Supplementation of standard antibiotic therapy with oral probiotics for bacterial vaginosis and aerobic vaginitis: a randomised, double-blind, placebo-controlled trial. BMC Women's Health 2015; 15 (115): 1-12.
Royal College of General Practitioners. The management of vulval skin disorders. [nternet] December 2015. [Cited 20 February 2020]. Available from http://www.snhcic.org.uk/assets/cmspage media/211/RCOG%20-%20Vulval%20Skin%20Disorders.pdf.
Arab H, Almadani L, Tahlak M, et al. The Middle East and Central Asia guidelines on female genital hygiene. BMJ Middle East 2011; 19: 99–106.
Bahamondes M, Portugal P, Brolazo E, Simões J, Bahamondes L. Use of a lactic acid plus lactoserum intimate liquid soap for external hygiene in the prevention of bacterial vaginosis recurrence after metronidazole oral treatment. Rev Assoc Med Bras 2011; 57 (4): 415-20.
Chen Y, Bruning E, Rubino J, Eder SE. Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage. Womens Health (Lond). 2017; 13 (3): 58-67.