Management of Genital Infections in Patients with Diabetes

Treatment Approach

For genital candidiasis secondary to SGLT2 inhibitor use, topical antifungal agents such as clotrimazole or miconazole applied twice daily for 7-14 days are the first-line treatment, with oral fluconazole 150 mg as a single dose recommended for moderate to severe cases, as supported by the Infectious Diseases Society of America 1
Oral fluconazole 150 mg as a single dose can be combined with topical therapy for faster symptom relief, and for fluconazole-refractory disease, consider itraconazole solution or posaconazole, with a strength of evidence based on clinical guidelines 1
Topical antifungal agents, including clotrimazole 1% cream, miconazole 2% cream, and nystatin cream, can be applied twice daily for 7-14 days, with a recommended treatment duration of 7-14 days 1

Patients on SGLT2 inhibitors should be counseled on preventive measures, including maintaining good genital hygiene, keeping the genital area clean and dry, wearing loose-fitting cotton underwear, and avoiding prolonged moisture in the genital area, as recommended by the Centers for Disease Control and Prevention and the American College of Physicians 2, 3, 4
The decision to continue or discontinue the SGLT2 inhibitor depends on infection severity and recurrence, with continuation recommended for first episode (mild) cases while treating the infection and implementing preventive measures, based on clinical guidelines 2, 3
For recurrent or severe infections, consider temporary discontinuation of SGLT2 inhibitor during treatment, and for refractory cases, permanent discontinuation of SGLT2 inhibitor may be necessary, although this is not directly cited, the benefits of SGLT2 inhibitors are mentioned, with a strength of evidence based on clinical trials 2, 3

Despite the risk of genital infections, SGLT2 inhibitors provide significant cardiovascular and renal benefits in patients with type 2 diabetes and chronic kidney disease, so continuation is generally recommended when possible, as supported by the American College of Physicians and the Infectious Diseases Society of America 2, 3
The American College of Physicians recommends confirming the diagnosis by examining for typical signs: erythema, pruritus, and white patches in the perianal region, performing a potassium hydroxide (KOH) preparation to visualize yeast or hyphae, and considering fungal culture in recurrent or resistant cases to identify non-albicans species, with a strength of evidence based on clinical guidelines 1
Maintenance therapy with weekly application of topical antifungal for 1-2 months or fluconazole 150 mg weekly for 6 months may be considered for cases with concurrent vulvovaginal candidiasis, as recommended by the Infectious Diseases Society of America 1
Treating sexual partners in recurrent cases may be considered, according to the Centers for Disease Control and Prevention, with a strength of evidence based on clinical guidelines 4
Patients should return for follow-up only if symptoms persist or recur within 2 months of treatment, as recommended by the Centers for Disease Control and Prevention, with a strength of evidence based on clinical guidelines 4

Inadequate treatment duration and failure to address predisposing factors are common pitfalls in the treatment of genital candidiasis, as noted by the Centers for Disease Control and Prevention 4
Missing concurrent infections, such as vaginal candidiasis, and overuse of corticosteroids can also lead to treatment failure, with a strength of evidence based on clinical guidelines 4