WASHINGTON -- Recurrent vulvovaginal candidiasis often isn't.
Recurrent bacterial vaginosis, genital herpes, and contact dermatitis are among the many entities that tend to be misdiagnosed as candida infections in women with recurrent vulvovaginal itching, burning, and soreness, Dr. Jack D. Sobel said at an ob.gyn. update on sexually transmitted diseases sponsored by OB.GYN. NEWS and Boston University.
"You need to inspect the vulva before you insert the speculum," advised Dr. Sobel, professor and chief of infectious diseases at Wayne State University, Detroit.
Genital herpes, for example, presents commonly with a fissure--not a blister or ulcer, as is often assumed. Without careful vulvar examination, the fissure is easily missed. In the meantime, the patient's accompanying erythema and edema are mistaken for a recurrent yeast infection. She gets a prescription for fluconazole, and the symptoms subside in 45 days--which just happens to be the normal time for resolution of herpes lesions.
Another common scenario is when a woman's frequent vulvar irritation or itch turns out to be caused by her use of various deodorants, douches, or fragrance-embedded menstrual pads. These can lead to maceration and irritation, which may indeed result in a secondary candida infection that will require a new prescription and perpetuate a vicious cycle. Other vulvovaginal syndromes that may be mistaken for a yeast infection without a closer look include idiopathic vulvar vestibulitis syndrome, atrophic vulvovaginitis (or atrophic vestibulitis), physiologic leukorrhea, or dermatoses such as lichen sclerosus.
It's important to get a history from the patient about systemic illnesses that could explain the symptoms, such as psoriasis or any allergic diatheses. "Whatever you capture in your history must go into your differential diagnosis," Dr. Sobel. said. Examine the patient's legs, knees, elbows, hands, and behind her ears. Dermatologic problems such as psoriasis or eczema may also manifest in the vulvovaginal area. "If she is complaining of pruritus vulvae, ask if she has pruritus elsewhere."
In general, "If the patient tells you she doesn't respond to terconazole or fluconazole, believe her. She's usually telling you she doesn't have candida."
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