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МЕСТНАЯ ТЕРАПИЯ КАНДИДНЫХ ВУЛЬВОВАГИНИТОВ

МЕСТНАЯ ТЕРАПИЯ КАНДИДНЫХ ВУЛЬВОВАГИНИТОВ

Профессор Ю.В. Сергеев, Т.А. Романовская, к.м.н. А.Ю. Сергеев
Поликлиника Медицинского центра УД Президента РФ, Москва Лечение вульвовагинального кандидоза (ВВК) до настоящего времени остается одной из важнейших проблем в гинекологии и дерматовенерологии. В последние годы наблюдался рост заболеваемости ВВК, в результате чего сейчас эта инфекция стоит на втором месте среди всех инфекций влагалища и является одной из наиболее распространенных причин обращения к гинекологу [1, 3].
К 25 годам более чем половине современных женщин хотя бы один раз ставился диагноз вагинального кандидоза [2]. По данным зарубежных исследований, 75% женщин детородного возраста имели один эпизод ВВК, а 50% и повторный эпизод. Основными факторами риска вагинального кандидоза считаются беременность, использование средств контрацепции, лечение антибактериальными препаратами и сахарный диабет. Колонизация и заболеваемость возрастают во время беременности, встречаясь не менее чем у 30% и 20% беременных соответственно. В целом при беременности заболеваемость ВВК возрастает примерно на 1020%. Первый эпизод ВВК у многих женщин отмечается именно во время беременности. Наиболее высокая степень колонизации отмечается в последнем триместре и у первородящих.

Основной целью лечения ВВК является прежде всего эрадикация возбудителя. Наличие специфических симптомов наряду с лабораторным свидетельством кандидной колонизации и воспалительных явлений должно убеждать врача в том, что ему необходимо лечить в первую очередь не расстройство вагинального микроценоза и не предрасполагающие состояния, а инфекцию, вызванную Candida spp. Зачастую практикуемые комплексные подходы, учитывающие массу сопутствующих факторов и предполагающие одновременное воздействие на них, приводят к необоснованной полипрагмазии, излишнему усложнению схемы лечения как для врача, так и для пациента, а иногда способствуют торпидному течению заболевания.

Большинство случаев ВВК поддается терапии местными противогрибковыми средствами и антисептиками.

Преимуществами местных средств являются относительная безопасность (в сравнении с системными препаратами), высокие концентрации антимикотиков, создаваемые на поверхности слизистой, и меньшая вероятность развития устойчивости. Кроме того, многие антимикотики местного действия быстрее обеспечивают исчезновение симптомов, в основном за счет мазевой основы. При выраженных симптомах заболевания местные средства предпочитают системным.

Местные противогрибковые средства выпускаются в специальных формах вагинальных суппозиториях и таблетках, кремах (см. табл.).



Все местные современные антимикотики относятся либо к химиотерапевтическим препаратам - производным имидазола, либо к группе полиеновых антибиотиков.

Препараты из группы азолов in vitro проявляют преимущественно фунгистатическое действие, нарушая синтез эргостерола, компонента мембраны грибов. Полиеновые антибиотики отличаются первично фунгицидным действием, непосредственно действуя на клеточную мембрану.

Из азольных антимикотиков в России зарегистрированы вагинальные формы изоконазола, клотримазола, миконазола и эконазола, из полиеновых антибиотиков используется натамицин (Пимафуцин), а также разные формы нистатина. По спектру действия производные имидазола примерно одинаковы.

Натамицин противогрибковый антибиотик из ряда полиеновмакролидов, продуцируемый актиномицетом Streptomyces natalensis. Подобно прочим полиеновым антибиотикам, натамицин связывается с эргостеролом, нарушая проницаемость мембраны. За счет этого создается фунгистатический и фунгицидный эффект.

Широкий спектр действия позволяет использовать натамицин для лечения многих поверхностных микозов. Основным показанием к назначению натамицина остается кандидоз кожи и вагинальный кандидоз. Натамицин действует также и на трихомонады и потому может назначаться при смешанной кандиднотрихомонадной инфекции. Кроме того, препарат может быть назначен при дерматофитозе (в дополнение к лечению системными антимикотиками), Malasseziaинфекции и в качестве средства для лечения вторичного подкожного аспергиллеза или феогифомикоза, осложняющего ранения и ожоги, а также при пересадке кожи. Местные формы натамицина применяются и в терапии отомикозов.

Для местного использования применяют крем, мазь и вагинальные свечи натамицина. Крем с 2% содержанием натамицина выпускается в тубах по 30 г. Вагинальные свечи содержат 100 мг натамицина каждая, в их состав входит также этиловый спирт. В упаковке содержится 3 овули.

Таблетки Пимафуцина применяются для лечения и профилактики кандидного дисбактериоза кишечника. Комбинированный препарат Пимафукорт содержит помимо натамицина неомицин и гидрокортизон.

Местные антисептики включают традиционно используемые для лечения разных инфекций средства и их современные модификации. Широко распространены спринцевания, аппликации, промывания, ванночки с растворами соды, борной кислоты, марганцовокислого калия, анилиновых красителей. Рекомендуемая продолжительность лечения любым из местных антисептиков не менее 2 нед.

При выраженном вульвите назначают теплые ванночки с содой, местные кортикостероидные кремы III классов (например, с гидрокортизоном, преднизолоном). Высокоактивные кортикостероидные мази IIIIV классов могут привести к обострению, усилению симптомов. Среди современных комбинированных препаратов, сочетающих противогрибковый компонент и кортикостероид, обращает на себя внимание Пимафукорт.

Патогенетическая терапия обострений включает также использование антигистаминных препаратов (совместимых с пероральными азольными антимикотиками) и кетотифена.

Учитывая, что беременность является главным среди предрасполагающих к ВВК факторов, особой проблемой является лечение вульвовагинального кандидоза при беременности. По данным сравнительных исследований, при беременности не установлена необходимость в более продолжительных курсах лечения. На первый план при ВВК во время беременности выходят вопросы безопасности лечения.

При беременности и лактации системные противогрибковые препараты вообще не используются. При лечении ВВК у беременных местные имидазольные антимикотики также не рекомендуется использовать, несмотря на то, что они эффективнее препаратов нистатина [5]. Натамицин (Пимафуцин) разрешается использовать при беременности [4]. Эффективность применения натамицина при ВВК, по данным зарубежных авторов, составляет 8594%. Отечественные гинекологи указывают на клиникомикологическую эффективность Пимафуцина, достигающую 86%.

Хронические формы заболевания, неоднократно леченные, протекающие на фоне сахарного диабета, хронических заболеваний и иммунодефицита, относятся к категории осложненного вульвовагинального кандидоза, плохо поддающегося терапии.

Неудачи системной и местной терапии редко бывают связаны с селекцией устойчивых штаммов грибов. Однако наблюдаются случаи устойчивости возбудителя как к системным препаратам из группы азолов, так и к местным антимикотикам. Последние, в частности, клотримазол, могут вызывать и контактный аллергический вульвовагинит.

Общей рекомендацией по лечению осложненных форм кандидного вульвовагинита является удлинение терапевтической схемы. При использовании местных средств продолжительность лечения возрастает вдвое (10 дней вместо 5, 2 недели вместо 1, повторный прием той же дозы через неделю при однократном назначении и т.д.). На наш взгляд, местной противорецидивной терапии следует отдавать предпочтение.

Тем не менее у части больных заболевание склонно к рецидивированию, несмотря на проведенные курсы длительной терапии. В этих случаях приходится назначать длительную противорецидивную терапию по наиболее удобным для пациента схемам. Продолжительность терапии может достигать нескольких лет.

Следует помнить, что среди распространенных причин неудачного лечения плохое соблюдение пациентками предписанной схемы, невыполнение врачебных рекомендаций, а также самостоятельное использование местных антимикотиков еще до момента обращения ко врачу.

Борьба с рецидивами вульвовагинального кандидоза включает коррекцию предрасполагающих к нему состояний: хронических инфекционных и прочих заболеваний, сахарного диабета, расстройств иммунитета. В связи с частой аллергизацией больных не рекомендуется назначение иммунокорректоров без предварительного исследования иммунологического статуса и типа гиперчувствительности.

Использование эубиотиков для коррекции кишечного дисбиоза при вагинальном кандидозе не имеет научного обоснования, но тем не менее распространено во врачебной практике. Наряду с медицинскими препаратами, содержащими концентраты бактерий, применяются обогащенные ими биопродукты. В то же время в период развития клинических проявлений ВВК кандидная колонизация кишечника достоверно выше. Для эрадикации кишечного резервуара могут быть использованы неабсорбируемые пероральные антимикотики, в частности таблетированные полиеновые средства нистатин и натамицин, не оказывающие системного действия, среди них таблетированная форма Пимафуцина отличается наибольшей эффективностью.

Литература:

1. Сергеев А. Ю., Сергеев Ю. В. Кандидоз: природа инфекции, механизмы агрессии и защиты, диагностика и лечение. М., 2000, 472 с.

2. Сергеев А. Ю., Иванов О. Л., Караулов А. В. и соавт. Вагинальный кандидоз: этиология, эпидемиология, патогенез. // Иммунопатология, аллергология, инфектология, 2000; 2: 99107.

3. Прилепская В. Н., Анкирская А. С., Байрамова Г. Р., Муравьева В. В. Вагинальный кандидоз. М., 1997, 40 c.

4. Тютюнник В. Л. Вагинальный кандидоз и беременность: этиология, патогенез, клиника, диагностика, лечение. // 2001, 1 (3): 8991.

5. Young GL, Jewell D. // Cochrane Database Syst. Rev., 2001; 4: CD000225.

Опубликовано с разрешения администрации Русского Медицинского Журнала.

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