Recent Advances in Vaginal Delivery for the Treatment of Vulvovaginal Candidiasis

Vulvovaginal candidiasis-an overview of current trends and the latest treatment strategies

Vulvovaginal candidiasis (VVC) is becoming more common, mostly affecting hospitalized and immunocompromised people. Candida albicans, among other species, is a significant causal agent, accounting for 90 % of infections. VVC, which affects up to 75 % of women, causes physical and psychological problems, with Candida albicans being associated in 85-95 % of cases(Dantas-Medeiros et al., 2023, Tomas et al., 2021, Dantas-Medeiros et al., 2021). Its physical symptoms include genital discomfort, decreased sexual pleasure, and psychological suffering. According to comparative research, pregnant women had a greater VVC prevalence, which can be ascribed to hormonal changes, poor hygiene, and diabetes. Antifungal medicines, which are widely used for therapy, have resulted in resistance issues, demanding a rethinking of therapeutic techniques. There are still diagnostic hurdles, with symptoms overlapping with other illnesses necessitating rigorous examination and laboratory tests. Recurrent Vulvovaginal Candidiasis (RVVC) affects 138 million women each year, causing morbidity and lowering quality of life. Financial constraints highlight the importance of novel, well-tolerated medicines. Resistance to antifungal drugs, notably azoles, complicates therapy. Probiotics, which focus on vaginal microbiome balance, appear as viable preventative strategies. From menarche to menopause, hormonal changes increase susceptibility to VVC, with estrogen playing a critical role. The growing resistance and limited antifungal alternatives, translating research in to clinical practice is critical. Current care is based on antifungals, but problems continue, necessitating the investigation of new drugs. Oteseconazole and ibrexafungerp show promise and have the potential to change RVVC therapy. While useful, probiotics generally supplement standard antifungal methods. In conclusion, tackling the growing difficulties of VVC necessitates ongoing research, novel therapeutics, and possible vaccine development in order to reduce the significant worldwide burden presented by this common fungal illness.

n-butanol extract of Pulsatilla decoction alleviates vulvovaginal candidiasis via the regulation of mitochondria-associated Type I interferon signaling pathways

ETHNOPHARMACOLOGICAL RELEVANCE

Vulvovaginal candidiasis (VVC) is a relatively common fungal infectious disease in the female reproductive tract. The pathogenesis of VVC not only involves Candida albicans (C. albicans) infection, but also the improper immune response of the vaginal mucosal immune system to the fungus. As a classical formula, Pulsatilla decoction has been proven to exert protective effect in both clinical and experimental research in VVC. However, the specific mechanism of Pulsatilla decoction in VVC remains elusive. This study investigated the mechanism of n-butanol extract of Pulsatilla decoction (BEPD) in treating VVC from the perspective of type I interferon signaling and related mitochondrial function.

MATERIALS AND METHODS

A VVC-rat model was developed using an estrogen-based method to evaluate the effectiveness of BEPD in treating VVC, and the therapeutic efficacy of BEPD against VVC was comprehensively evaluated by fungal morphology and burden, neutrophil numbers, histopathology, pro-inflammatory and anti-inflammatory cytokines production, and LDH level. Immunohistochemistry (IHC), immune fluorescence (IF), Western Blot (WB) and RT-qPCR assays were conducted to assess type I interferon signaling and mitochondria functions. Candidalysin-induced vaginal epithelial inflammation in vitro, as cellular models, was employed to detect the changes in type I interferon signaling and mitochondria function before and after BEPD-containing serum intervention.

RESULTS

BEPD could significantly improve the inflammation, reduce fungal loads and inhibit fungal growth, balance pro-inflammatory and anti-inflammatory cytokine levels in VVC model rats. The findings from IHC, IF, WB and RT-qPCR revealed that BEPD could promote type I interferon signaling and alleviate mitochondrial functional damage in VVC model rats, and BEPD-containing serum could play the same role in vitro.

CONCLUSION

The study findings generally demonstrated that BEPD could improve the inflammation and correct the immune imbalance in VVC through regulation of type I interferon signaling and mitochondrial function.

Transcriptomics Reveals Effect of Pulsatilla Decoction Butanol Extract in Alleviating Vulvovaginal Candidiasis by Inhibiting Neutrophil Chemotaxis and Activation via TLR4 Signaling

The Pulsatilla decoction is a well-known herbal remedy used in clinical settings for treating vulvovaginal candidiasis (VVC). However, the specific mechanism that makes it effective is still unclear. Recent studies have shown that in cases of VVC, neutrophils recruited to the vagina, influenced by heparan sulfate (HS), do not successfully engulf Candida albicans (C. albicans). Instead, they release many inflammatory factors that cause damage to the vaginal mucosa. This study aims to understand the molecular mechanism by which the n-butanol extract of Pulsatilla decoction (BEPD) treats VVC through transcriptomics. High-performance liquid chromatography was used to identify the primary active components of BEPD. A VVC mouse model was induced using an estrogen-dependent method and the mice were treated daily with BEPD (20 mg/kg, 40 mg/kg, and 80 mg/kg) for seven days. The vaginal lavage fluid of the mice was analyzed for various experimental indices, including fungal morphology, fungal burden, degree of neutrophil infiltration, and cytokines. Various assessments were then performed on mouse vaginal tissues, including pathological assessment, immunohistochemistry, immunofluorescence, Western blot (WB), quantitative real-time PCR, and transcriptome assays. Our results showed that BEPD reduced vaginal redness and swelling, decreased white discharge, inhibited C. albicans hyphae formation, reduced neutrophil infiltration and fungal burden, and attenuated vaginal tissue damage compared with the VVC model group. The high-dose BEPD group even restored the damaged vaginal tissue to normal levels. The medium- and high-dose groups of BEPD also significantly reduced the levels of IL-1β, IL-6, TNF-α, and LDH. Additionally, transcriptomic results showed that BEPD regulated several chemokine (CXCL1, CXCL3, and CXCL5) and S100 alarmin (S100A8 and S100A9) genes, suggesting that BEPD may treat VVC by affecting chemokine- and alarmin-mediated neutrophil chemotaxis. Finally, we verified that BEPD protects the vaginal mucosa of VVC mice by inhibiting neutrophil recruitment and chemotaxis in an animal model of VVC via the TLR4/MyD88/NF-κB pathway. This study provides further evidence to elucidate the mechanism of BEPD treatment of VVC.

N-3-Methylbutyl-benzisoselenazol-3(2H)-one Exerts Antifungal Activity In Vitro and in a Mouse Model of Vulvovaginal Candidiasis

In the present work, we evaluated the antifungal activities of two novel ebselen analogs, N-allyl-benzisoselenazol-3(2H)-one (N-allyl-bs) and N-3-methylbutylbenzisoselenazol-3(2H)-one (N-3mb-bs). Colorimetric and turbidity assays were performed to determine the minimum inhibitory concentration (MIC) of these compounds in S1 (fluconazole-sensitive) and S2 (fluconazole-resistant) strains of C. albicans. N-3mb-bs was more active than the N-allyl-bs compound. It is noteworthy that the concentration of N-3mb-bs observed to inhibit fungal growth by 50% (18.2 µM) was similar to the concentration observed to inhibit the activity of the yeast plasma membrane H+-ATPase (Pma1p) by 50% (19.6 µM). We next implemented a mouse model of vulvovaginal candidiasis (VVC) using the S1 strain and examined the mouse and yeast proteins present in the vaginal lavage fluid using proteomics. The yeast proteins detected were predominately glycolytic enzymes or virulence factors associated with C. albicans while the mouse proteins present in the lavage fluid included eosinophil peroxidase, desmocollin-1, and gasdermin-A. We then utilized the N-3mb-bs compound (12.5 mg/kg) in the mouse VVC model and observed that it significantly reduced the vaginal fungal burden, histopathological changes in vagina tissue, and expression of myeloperoxidase (MPO). All in all, the present work has identified a potentially promising drug candidate for VVC treatment.

Optimization of a Mucoadhesive Vaginal Gel Containing Clotrimazole Using a D-Optimal Experimental Design and Multivariate Analysis

The aim of this study was to develop a suitable clotrimazole (CLT)-loaded mucoadhesive vaginal gel (CLT-MVG) for topical applications in vaginal candidiasis. Ten CLT-MVG formulations were prepared, consisting of mixtures of acid polyacrylic (Carbopol 940) and polyethene oxides, Sentry Polyox WSRN 1105 or 750, according to an experimental D-optimal design, and CLT was suspended at a ratio of 1%. The prepared CLT-MVG formulations were studied in vitro, and the formulation containing Carbopol 940 0.89% combined with PEO 1105 1.39% was identified with the optimal rheological and in vitro bioadhesion properties, ensuring the prolonged release of CLT, with a similarity factor greater than 50, indicating dissolution profile similarity for three batches of the optimized formulation. This optimized formulation showed a pH in the tolerance range, and an adequate ex vivo mucoadhesion time, while the FT-IR studies revealed no interactions between the excipients and CLT. The microscopic analysis identified a mean particle size of suspended CLT of 5.24 ± 0.57 μm. The in vitro antifungal activity of the optimized formulation was tested on twenty strains of Candida albicans and proved to be better compared to a marketed clotrimazole preparation, showing a greater inhibition effect (p < 0.05). The optimized formulation could be a good candidate for the local treatment of vaginal mycosis.