http://informahealthcare.com/drdISSN: 1071-7544 (print), 1521-0464 (electronic)

Drug Deliv, Early Online: 114! 2014 Informa Healthcare USA, Inc.. DOI: 10.3109/10717544.2014.928760

REVIEW ARTICLE

Advanced topical drug delivery system for the management of vaginalcandidiasis

Himmat Singh Johal, Tarun Garg, Goutam Rath, and Amit Kumar Goyal

Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, India

Abstract

Vaginal candidiasis or vulvovaginal candidiasis (VC) is a common mucosal infection of vagina,mainly caused by Candida species. The major symptoms of VC are dyspareunia, pruritis, itching,soreness, vagina as well as vulvar erythema and edema. Most common risk factors that lead tothe imbalance in the vaginal micro biota are the use of antibiotics, pregnancy, diabetesmellitus, immuno suppression as in AIDS or HIV patients, frequent sexual intercourse,spermicide and intra-uterine devices and vaginal douching. Various anti-fungal drugs areavailable for effective treatment of VC. Different conventional vaginal formulations (creams,gels, suppositories, powder, ointment, etc.) for VC are available today but have limited efficacybecause of lesser residence time on vaginal epithelium due to self-cleansing action of vagina.So to overcome this problem, an extended and intimate contact with vaginal mucosa is desired;which can be accomplished by utilizing mucoadhesive polymers. Mucoadhesive polymers havean excellent binding capacity to mucosal tissues for considerable period of time. This uniqueproperty of these polymers significantly enhances retention time of different formulations onmucosal tissues. Currently, various novel formulations such as liposomes, nano- andmicroparticles, micro-emulsions, bio-adhesive gel and tablets are used to control andtreat VC. In this review, we focused on current status of vaginal candidiasis, conventionaland nanotechnology inspired formulation approaches.

Keywords

Bio-adhesive polymers, liposomes,nanotechnology, novel drug deliverysystems, vaginal candidiasis

History

Received 5 May 2014Revised 23 May 2014Accepted 23 May 2014

Introduction

Vaginal candidiasis (VC) often referred to as vulvovaginal

candidiasis, is a common mucosal infection of vagina, mainly

caused by Candida species (Alexander et al., 2004) and

alleged to be the second most prevalent mucosal infection

after bacterial vaginosis. It is a far-flung infectious disease

affecting about 75% of women of reproductive age (Song

et al., 2004). In the United States alone, annually 13 millions

of cases of VC are observed which further results in

10 million gynecologic office visits (Francois et al., 2003).

In 2002 in United States, women spend over half a billion

dollars on the medication for the treatment of VC, and about

half of this amount was spend on over the counter medicines

(Jyotsana et al., 2010). This is despite the fact that most of the

women may wrongly diagnose VC as bacterial vaginosis

(De Blaey & Polderman, 1980). The major symptoms of VC

are dyspareunia, pruritis, itching, soreness, signs of vagina

and vulvar erythema and edema (Lee, 1990; Francois et al.,

2003). Candida species, especially Candida albicans is

responsible for VC. It is a dimorphic commensal organism

that domiciliation on skin, mucosa and gastrointestinal tract

of 3050% of normal healthy individual. Candida albicans is

not a pathogen, but when local or systemic defense mechan-

ism of the host got afflicted, Candida spp. can induce

oropharyngeal, esophageal or VC (Woolfson et al., 2000).

Under normal healthy conditions, lactobacillus in vagina

produces lactic acid, which act as buffer and maintains the pH

of vagina in the range 45 (acidic) and bacteriocins and

hydrogen peroxide (H2O2), which resist the overgrowth of

pathogenic microbes. In certain ill conditions, when this

balance gets disturbed, there occurs excessive overgrowth of

Candida sp. and diminution or depletion Lactobacillus spp.

Following the overgrowth, there are two crucial elements

responsible for the developments of VC are vaginal epithe-

lium colonization and transformation of asymptomatic

(saprophytic phase) to symptomatic (pathogenichyphal

phase). Most common risk factors that lead to the imbalance

in the vaginal micro biota are the use of antibiotics,

pregnancy, diabetes mellitus, immuno suppression as in

AIDS or HIV patients, frequent sexual intercourse, vaginal

douching, spermicide and intra-uterine devices (Gagandeep

et al., 2014). Most commonly used drugs for VC are

Fluconazole, Clotrimazole, Metronidazole, Miconazole,

Econazole, Ticonazole, Voriconazole, and Isoconazole.

In pharmaceutical literature, vagina is described as slightly

S-shaped fibro muscular, collapsible tubular organ of

approximately 610 cm length that extends from cervix of

the uterus to the vestibule of the external genitalia

Address for correspondence: Amit Kumar Goyal, ISF College ofPharmacy, Moga, Moga, Punjab 142001, India. Email: amitkumargoyal1979@gmail.com

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(Washington et al., 2000; Woolfson et al., 2000) and has two

main functions: (1) Serves as receptacle for penis during

sexual intercourse and carries sperm to the uterus and

fallopian tubes. (2) As a birth canal for the passage of the

baby during labor. The vagina comprises of three different

cell layers: epithelial layer (superficial layer), lamina propria

or tunica, muscular coat (D Amati et al., 2003). Overall of

1015 layer cell turnover is expected in the time period of 7 d

(Sjoberg et al., 1988). A brief description of vaginal anatomy

and physiology is presented in Table 1.

Pathophysiology of vaginal candidiasis

A normal healthy micro floral balance of Lactobacillus sp.

and Candida sp. exists in vagina. When this balance gets

disturbed due to certain risk factors, there occurs excessive

growth of Candida sp. (Virulent). This is followed by cascade

of reactions that finally leads to damage to vaginal epithelium

and then symptoms get precipitated and VC occurs (Figure 1).

Adhesion to vaginal epithelia

The initial and critical step toward fungal infections is the

adhesion of Candida to epithelial cells. Candida albicans

interacts by colonization and proliferation on epithelial cells

followed by invasion, dissemination and damage. Cell wall

components of Candida play a key role in adhesion process.

Different cell wall protein adhesion candidates are:

The Als (agglutinin-like sequence) family: Till date 8 ALS

genes have been recognized ALS 1ALS 7 and ALS 9, that

are involved in adhesion. N terminus of ALS protein is

involved in ligand binding (Loza et al., 2004; Rauceo et al.,

2006; Liu & Filler, 2011). Study of ALS-deleted mutants have

variable effect on adhesion like expression of C. albicans

ALS1 or ALS5 genes in non-adhesive, ALS4 deletion

decreases C. albicans adherence to endothelial cell.

Hypha-associated genes: Hyphal wall protein (Hwp 1),

major protein on hyphal cell wall. Its N-terminal domain

serves as a substrate for epithelium transglutaminases. Thus, a

strong covalent linking occurs between Hwp and epithelium

proteins. Eap1, and Int1, also involved in adhesion but their

binding ligands are unknown.

Integrin am b2-like adhesins: Different ligands, includingiC3b, fibrinogen, factor X, urokinase receptor, CD14, CD23,

CD54 (ICAM-1), CD102 (ICAM-2), CD242 (ICAM-4),

heparin, haptoglobin, kininogen, and various microbial pro-

teins (Haas & Plow, 1994). Out of these molecules, only

ICAM-1 and -2 are widely expressed on endothelial cells.

Integrin av b3 and avb5-like adhesins: av b3 like adhesionhas been shown to bind to vitronectin (Spreghini et al., 1999;

Santoni et al., 2001), but other ligands for av b3 includeCD31 (PECAM-1), Fibronectin, fibrinogen, thrombospondin,

von Willebrand factor, and RGD sequence peptides (Haas &

Plow, 1994). CD31 is expressed by endothelial cells and could

act as a direct ligand for Candida adhesion avb5 vitronectin, RGD sequence peptides but lack epithelium

specific binding ligand (Jouault et al., 2006).

Transmigration vaginal epithelium

After adhesion, next step is the migration across vaginal

epithelium. Different mechanism through which Candida

migrates is:

Induced endocytosis: Two Candida invasions, ALS 3 and

SSA 1 (SSA 1 is a member of the heat Shock protein (HSP)

70 family that is expressed on the cell surface). Present in

hyphal cell wall and induce endocytosis. These binds to

E- cadherin, then tyrosine phosphorylation occurs that leads

to microfilament rearrangement and then leads to pseudopod

formation and subsequent engulfment into the cell through

clathrin mediated actin-dependent mechanism.

Table 1. Anatomy and physiology of vagina.

Vaginal physiology Characteristics Description

Epithelium Stratified,Non-keratinized squamous

Thickness is higher in postmenopausal women than premenopausal women 25 layered thick estrogen content act as a dominant physical barrier Have numerous folds, known as Rague (Hussain & Ahsan, 2005);

which helps in easy incorporation of different formulations and enhancesabsorption of drugs by providing distentibility, support, increasing surfacearea (Choudhury et al., 2011).

Vaginal secretion Vagina does not possess any gland (Paavonen,1982). Vaginal fluid comprises of exudatesfrom blood vessels, secretion from fallopiantubes, peritoneal, uterine, Bartholins andScenes gland (Francois et al., 2003)

Fluid provide moisture Solubilize solid dosage formulations in vagina Volume and composition of vaginal fluid varies with age, infection, sexual

arousal (Masters & Johnson, 1966)

pH Range of 3.54.5(average 4.2)

Lactobacillus sp. produces lactic acid from glycogen, which helps inmaintaining healthy acidic conditions in vagina

Varies with age (new born 45, pre-puberty 7, puberty 57, childbearing 45, pregnancy 35, menopause 67 and post meno-pause 77.4).

Ionization of ionic drug alter with slight shift in vaginal pH; thus changesstability, solubility and absorption of drugs

Micro flora Vagina has a complex micro-ecological system Lactobacillus is the predominant flora in vagina It produces lactic acid, H2O2, bacteriocins, thus maintains acidic vaginal

environment and also resist growth of pathogenic micro-organisms Composition of vaginal flora varies with menstrual cycle, gestation, use of

contraceptives, frequency of sexual intercourse, etc. Candida sp. concentration reaches peak level in pre-menstrual period.

2 H. S. Johal et al. Drug Deliv, Early Online: 114

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Active penetration: Fungi must be viable and changes tohyphal form during or after the penetration. Sap enzymes

primarily contribute to active penetration. Sap (Secreted

aspartic proteinases) 5 degrade E- cadherin of epithelial cell

and violate integrity of vaginal epithelium, thereby enabling

hyphal penetration into epithelial cells.

Damage: Once Candida goes across vaginal epithelium, it

cusses severe damage by apoptosis and necrosis. However,

exact mechanism behind this is yet to be revealed.

Figure 2 represents diagrammatic description of vaginal

colonization of Candida Spp. Table 2 discusses the different

ligand specific adhesion and invasions involved in adhesion

and transmigration across vaginal epithelium.

Prevalence of vaginal candidiasis

VC has a wide geographical distribution all over the world

(Table 3). On the basis of various research papers it can be

Figure 1. Pathophysiology of vaginal candidiasis.

Figure 2. Diagrammatic description of vaginal colonization of Candida spp.

DOI: 10.3109/10717544.2014.928760 Drug delivery system for vaginal candidiasis 3

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concluded that C. albicans is the most dominant and prevalent

sp. in females with VC as it has an excellent binding capacity

for mucus membrane. Non-albicans species are contributing

to VC for a far lesser extent. VC with positive samples was

observed to occur on higher levels on USA and UK while

other countries had significant lesser number of positive

samples. Among all positive samples, occurrence of

C. albicans sp. was much higher than non-albicans sp.

Among non-albicans sp., C. glabrata was the most common

fungi found in subjects vagina. This vast variation was

observed in females which are illiterate, high school educa-

tion, married, having diabetes mellitus (Alli et al., 2011;

Faraji et al., 2012), frequent sexual intercourse, oral contra-

ceptives, spermicides (Alli et al., 2011), etc.

A concerning trend was observed in prevalence of

Candida sp. in different age groups. With increasing age,

a drastic fall in albicans sp. was observed; however, there

is a significant increase in distribution of non-albicans sp.

among which C. glabrata was the dominant one. Increase

in number of C. glabrata was also observed in elderly

diabetic patients (Vermitsky et al., 2008). This can be

justified, as continuous use of azole agents leads to develop-

ment of resistance in C. glabrata, which is characterized

by higher colonization of C. glabrata in vaginal epithelium

as compared to C. albicans. Thus for effective treatment

of VC, proper microscopic identification of virulent sp.

should be done. Non-azole anti-fungal drugs like Boric acid

and Flucytosine can be used for non-albicans species

(Ogunshe et al., 2008; Vermitsky et al., 2008; Abruquah,

2012).

Factor affecting vaginal drug absorption(Stewart-Tull, 1964; Hussain & Ahsan, 2005;Mathiowitz et al., 2013)

Like other mucosal routes, drug administrated via vaginal

route is absorbed by three major ways: (1) transcellularly;

mediated via concentration-dependent gradient (2) paracellu-

larly; through tight junctions present in between the cells

(3) vesicular or receptor-mediated transport as remarked

by Ilium and Richardson. Absorption of drug from vagina

follows two main steps: drug dissolution in vaginal lumen and

membrane penetration. So any factor influencing physiology

of vagina and formulation aspects like drug dissolution and

membrane transport will potentially alter the absorption

profile of drug from vaginal drug delivery systems (Garg

et al., 2014a). Different vaginal physiological factors that

influence drug absorption in vaginal cavity are discussed in

Table 4.

Available therapies for vaginal candidiasis

Various anti-fungal drugs are available for effective

treatment of VC. The treatment is initiated in symptomatic

women because they have 80% of Candida colonization

(Syed & Braverman, 2004). The endeavor of the treatment

is to prevent over-growth of Candida that precipitates

symptoms. Almost 37 d are sufficient for effective

results. Formulation other than oral, are usually administered

at night to prevent any leakage or removal from vagina.

There is no evidence available favoring any specific for-

mulation or any particular azole agent. However in case of

severe infection, oral preparations may not provide symp-

tomatic relief. In that case low-potency steroids as topical

formulations should be used (Cejtin & Mason, 2000).

Different oral and topical therapies available for VC are

given in Table 5.

While these therapies are quite effective, but

still associated with number of limitations like side effects,

drug interaction, contraindication, etc., as presented in

Table 6.

Table 3. Worldwide distribution of various Candida sp. responsible forvaginal candidiasis.

Candida

CountryTotal no.

of subjectsAlbicans

(%)Glabrata

(%)Parasilosis

(%)Krusei

(%)Tropicalis

(%)Other sp.

(%) References

IOWA 593 70 18.8 5 2 1.6 (Richter et al., 2005)USA 93 775 88.9 7.9 1.7 1.4 0.008 (Vermitsky et al., 2008)Nigeria 106 36.8 5.6 1.88 10.3 (Ogunshe et al., 2008)Iran 605 26.28 0.82 0.33 4.29 0.33 4.13 (Shafik et al., 2007; Faraji et al., 2012)Pakistan 250 12 3.2 4 1.2 8.4 3.2 (Khan & Baqai, 2010)India 350 17.42 2.5 0.5 0.8 1.4 0.5 (Jindal et al., 2007)Australia 275 15.63 4.3 1.09 0.3 (Pirotta & Garland, 2006)UK 548 86.86 2.7 0.5 0.1 0.7 0.9 (El-Din et al., 2001; Dias et al., 2011)Brazil 404 33.16 1.2 1.2 1.2 1.2 - (Sobel et al., 2004)

Table 2. Ligand specific adhesion and invasions involved in adhesionand transmigration across vaginal epithelium.

Interaction ofCandida withepithelium Candidates Ligand

Adhesion Als 1-7, 9 N- cadherinHwp 1 transglutaminasesEap1 UnknownInt1 UnknownIntegrin am b2-like

adhesinsICAM-1 and -2

Integrin av b3 likeadhesins

CD31 (PECAM-1),

N-linked mannosylresidues

Mannose receptor (MR)

O-linked mannosylresidues

Toll-like receptor 4(TLR-4)

Phospholipomannan TLR-2Mannosides galectin-3

Transmigration ALS 3 and SSA 1 E- cadherin,Sap enzymes E- cadherin,

4 H. S. Johal et al. Drug Deliv, Early Online: 114

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Conventional topical intravaginal delivery systems

Creams and gels

Creams and gels as intravaginal delivery systems are used to

deliver contraceptives and anti-bacterial agents (Garg &

Goyal, 2014a). However these systems are messy in use,

uncomfortable and because of non-uniformity and leakage,

exact dose can never be provided. The worthy properties of

vaginal creams and gels are acceptability; feasibility and non-

toxic, non-irritant nature towards vaginal mucosa. Vaginal

creams of metronidazole and clindamycin are found to be as

efficacious as the orally administered drugs for treatment of

bacterial vaginosis (Mcgregor et al., 1998). Oxytocin,

dinoprostone and misoprostol used for cervical ripening and

labor induction, can be administered in gel form. Shetty et al.

studied efficacy of dinoprostone vaginal gel against oral tablet

for induction of labor and observed significant difference

there. Several researchers are comparing efficacy of vaginal

gel with oral products for misoprostone, and the results

obtained leads to conflicting outcome. Hall et al. reported

that orally given misoprostone is far more safe and effective in

labor induction against when it is vaginally administered.

However, Shetty et al. concluded that among vaginally and

orally administered misoprostone, vaginal delivery was the

most effective. Vaccines can also be delivered intravaginal in

the form of gel.

Pesseries and suppositories

A variety of vaginal medications are available in form of

pesseries and suppositories. They are designed in such a way

to melt in vaginal cavity and release active medicament in

controlled manner. Suppositories are used for localized

delivery of drugs like anti-septic, anti-fungal and contracep-

tives. Primarily, they are used to deliver drugs like

dehydroepiandrosterone Sulphate (Yamashita et al., 1991)

for cervical ripening, prior to birth; miconazole for VC

(Vukovich et al., 1977; Abrams & Weintraub, 1983) and

progesterone for hormonal replacement therapy. Different

techniques for preparation of suppositories are hand-molding,

pour-molding or by automatic machine (Brannon-Peppas,

1993; Hussain & Ahsan, 2005) where drug is dispersed in

suppository base, e g. cocoa butter. Pesseries are known to

deliver prostaglandin E2 (PGE2) for cervical ripening and

labor induction. A semi-crystalline hydrogel of cross linked

polyethylene oxide swells in saturated solution of PGE2 to

give final product, pesseries.

Table 4. Factor affecting vaginal drug absorption.

Factors Sub-types Drug-related features

Physiological factors Vaginal epithelium thickness

Vaginal fluid

Cervical mucus

pH

Higher the epithelium thickness lesser will be permeability and vice versa; thusabsorption varies.

Example: as in case of steroids (Vermesh et al., 1988) and estrogen. In guinea pigs, in early disastrous stage, Vidarabine has shown a 5100 times

more permeability coefficient as compared to that in oestrous stage (Hwanget al., 1977).

Poorly water soluble drugs are more frequently absorbed when fluid volume ishigh.

However this condition may remove drug from vaginal cavity thus reducing drugabsorption (Owen et al., 1999).

Thick mucus is less permeable and vice versa. It act as permeability barrier for most of the drugs (Johnson et al., 1992). It can be exploited for bioadhesive delivery systems For pH-sensitive drugs and drugs which are weak electrolyte, alteration in vaginal

pH may alter drug ionization, solubility, stability and subsequent drugrelease(Katz & Dunmire, 1993).

Physicochemical factors Lipophilicity

Molecular weight

Solubility

Degree of ionization

Lipophilic steroids like progesterone and estrone have higher permeability ascompared to hydrophilic steroids i.e. hydrocortisone and testosterone (Robinson& Bologna, 1994).

Lipophilic drugs of low molecular weight are readily absorbed then highmolecular weight hydrophilic or lipophilic drugs.

As vaginal fluid have some water content so it favors absorption of drugs havingcertain solubility in water (Hwang et al., 1976).

Drugs like peptide, weak electrolyte are frequently absorbed in their unionizedform (Brannon-Peppas, 1993).

Table 5. Different available therapies for VC (Faro, 1994; Carr et al.,1998; Watson & Pirotta, 2011; Newson, 2013).

Agent Formulation Dose

Clotrimazole 1% cream 5 g, intravaginalfor 7 to 14 d

100 mg vaginal tablet 100 mg 7 d100 mg vaginal tablet 200 mg 3 d500 mg vaginal tablet 500 mg single dose

Miconazole 2% cream 5 g, intravaginal for 7 d100 mg, vaginal suppository 100 mg 7 d200 mg, vaginal suppository 200 mg 3 d1200 mg vaginal suppository 1200 mg single dose

Terconazole 80 mg vaginal suppository 80 mg 3 d0.4% cream, 5 g, 5 g 7 d0.8% cream, 5 g, 5 g 3 d

Ticonazole 6.5% ointment, 5 g, 5g single dose2% cream 5 g 3 d

Nystatin 100 000 IU, vaginal tablet, 100 000 IU, 14 dButoconazole 2% cream, 5 g, 3 dKetoconazole 200 mg oral tablet 400 mg 5 dFluconazole 150 mg oral capsule 150 mg single doseItraconazole 100 mg oral capsule 200 mg 3 d

DOI: 10.3109/10717544.2014.928760 Drug delivery system for vaginal candidiasis 5

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Vaginal tablets, powder and ointment

Vaginal tablets contain same components as that of conven-

tional oral tablets like binders, disintegrants and other

excipients. These are advantageous over the other dosage

form as have ease of manufacture and insertion. Usually

deliver prostaglandins and anti-fungal drugs like Itraconazole,

Clotrimazole, etc. Highly hydrophobic drugs are not suitable

candidates for vaginal tablets as they have poor absorption.

However, use of penetration enhancers like surfactants, bile

salts can overcome this problem. Sometimes mucoadhesive

polymers can be incorporated to enhance vaginal residence

time. Polystyrene sulfonate (PSS) when formulated as vaginal

tablet, have higher anti-microbial effect against HIV and HSV

and is neither cytotoxic nor it inhibit vaginal flora (Kast

et al., 2002). Vaginal powder is prepared by dissolving

Hydroxypropyl cellulose in water with continuous heating.

This mixture is then slightly cooled and bisphosphonate was

added. This final mixture was then lyophilized. Vaginal

ointment comprises of an aqueous phase and oil phase. Drug

was dissolved in the aqueous phase and the oil phase was

incorporated into it with mixing (Kaur et al., 2014).

Vaginal ring

Vaginal rings are circular device inserted in the vagina

to achieve controlled release of the active medicament.

These are approximately 5 cm in diameter and have 45 mm

of cross-sectional diameter. These are generally polymeric

rings in which the drug is homogeneously dispersed. These

offer several advantages: user controlled, deliver drug

continuously and do not interfere with coitus. From the

surface of the ring, drug release at faster rate as compared to

the inner layer of ring. This may provide an initial burst

release of the drug followed by sustained release for several

days. In order to achieve constant release, two types of system

are developed for vaginal rings: sandwich and reservoir type.

In sandwich type, a narrow layer of drug is placed between

non-medicated central core and non-medicated outer band. In

reservoir type, central core having the drug is encapsulated

with drug-free polymer layer (Garg & Goyal, 2012).

Commonly used polymers are poly (dimethylsiloxane) or

silicone devices. Moreover in the recent years, elastomeric

polymer like ethylene vinyl acetate and styrene are exten-

sively used, as it have increased flexibility, improved optical

properties, greater adhesion and increased impact and punch

resistance (Novak et al., 2003). Vaginal rings are most

commonly employed for hormonal replacement therapy and

contraceptives delivery. To deliver contraceptive, rings are

placed in vagina for 21 d followed by 1 week ring free for

menstrual cycle to take place. NuvaRing is a common

example of vaginal ring available in U.S market to deliver

contraceptives. It is transparent, flexible ring containing

Table 6. Drug associated limitations for anti-fungal therapy.

Anti-fungal drug Side-effect Drug interaction Contra-indications

Fluconazole Nausea, vomiting, abdominal pain,and diarrhea, have been reported inapproximately 5% of patients(Ernest, 1992).

Skin rash, acne, itch, headache,GI upset(Sobel et al., 1995)

Abnormal liver function in 5.1% ofpatients, Hepatotoxicity in AIDSpatient(Gearhart, 1994)

Cisapride Erythromycin, non-sedating antihistamines,

diuretics raise fluconazole levels. Dilantin, oral hypo-glycemic drugs benzodi-

azepines; theophylline and warfarin level canget elevated.

Cimetidine may limit efficacy of fluconazole.

Renal and hepatic dysfunctionPregnancy

Itraconazole Nausea, headache, dizziness(Stein &Mummaw, 1993) increased level oftransaminase enzyme

Reversible peripheral neuropathy(Hay, 1993) and reversible changesin liver function with low frequency

Quinidine Pimozide Dofetilide Modazolam Nisoldipine Ergotamine

Heart disease

Clotrimazole Vaginal burning, sensitive clitoris in(5%) Patients(Fong, 1992)

Cholecalciferol Acetaminophen Montelukast Gabapentin Furosemide Diphenhydramine Aspirin

Hepatic dysfunction

Ticonazole Local pruritis, local burning, vaginalirritation. recurrent candidiasis(30%)(Stein et al., 1986)

Cyclosporine, Methotrexate Prednisone

Hypersensitivity, diabetes

Ketoconazole Hepatotoxicity, alcohol intolerance,anorexia, increased appetite, headache,dizziness, insomnia hepatitis, jaundice,

Alprazolam Midazolam Triazolam Quinidine Amlodipine Felodipine Nicardipin Phenytoine Nifedipine Cyclosporine Tacrolimus

Liver disease, hypersensitivity

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etonogestrel and ethinyl estradiol and releases 120 mg/d of

former and 15 mg/d of later one over a period of 3-week.

Femring and Estring are employed for the hormonal replace-

ment therapy. Dapivirine also known as TMC 120 is given

in the form of ring acting as potent microbicide against

transmission of STIs and HIV. Plastic rings are sometimes

used to hold and support suppositories in position in vagina.

Limitations of conventional vaginal formulations

These conventional vaginal delivery systems are somewhat

effective; however, they still offer several disadvantages

which we need to encounter in order to deliver anti-fungal

therapy in an efficacious way. Disadvantages associated are:

Leakage and messiness as in case of creams and gel Uncomfortable Efficacy is quite low as gels may not provide an exact

dose because of non-uniformity and leakage

Low retention to the vaginal epithelium Poor patient compliance Frequent administration of drug is required Prolonged duration of therapy Low bioavailability Drug release pattern is inappropriate (Parnami et al.,

2013; Singh et al., 2014).

Novel approaches in vaginal formulations

Different conventional vaginal formulations for VC are

available today but have limited efficacy because of lesser

residence time on vaginal epithelium due to self-cleansing

action of vagina. This leads to frequent administration of the

formulation, which ultimately cause inconvenience to the

user. So to overcome this problem, an extended and intimate

contact with vaginal mucosa is desired; which can be

accomplished by utilizing mucoadhesive polymers.

Mucoadhesive polymers have an excellent binding capacity

to mucosal tissues for considerable period of time (Kataria

et al., 2014). This unique property of these polymers

significantly enhances retention time of different formulations

on mucosal tissues. Thus, controlled release can be fruitfully

achieved and in turn frequent administration of dosage forms

is prevented. Several bio-adhesive polymers are available like

polycarbophil, hydroxypropylcellulose, polyacrylic acid, chit-

osan, carbopol, etc.

Vaginal bio-adhesive tablets

Method for preparation of vaginal bio-adhesive tablets is

similar to those of normal tablet; however, they differ in

composition of excipients as the former have a single or

combination of bio-adhesive polymer and the latter one is

devoid of it. In case of evaluation of these tablets, additional

parameters are included like swelling index, bio-adhesion

time and bio-adhesive strength. The very first bio-adhesive

tablet prepared was of Bleomycin, antibiotic; containing

polymers like hydroxy propyl cellulose (HPC) and poly

acrylic acid (PAA) or Carbopol-934. It was observed that

with increasing amount of HPC, in-vitro release rate increases

and increment in concentration of PAA, water absorption

property rises. 5-Flurouracil and Carbaquinone, potent

anti-cancer drugs were also formulated in the tablet form

(Brannon-Peppas, 1993). Various anti-fungal agents are

formulated in form of bio-adhesive tablets are mentioned in

Table 7.

Vaginal liposome

Liposomes are the spherical vesicle, characterized on their

lipid composition, size, number of lamellae, and inner/outer

phases (Garg & Goyal, 2014b). Because of biocompatibility,

stability and structural versatility, these have been extensively

used for different therapies (Goyal et al., 2013). For having

high stability with good mucoadhesive strength, positively

charged vesicles are preferred over negative ones; as mucus

membrane is negatively charged (Garg et al., 2014b). Before

1990, liposomes were used for parenteral and skin delivery

but later on there was a drastic shift in their use in vaginal

drug delivery. Jain et al. utilized liposomes for vaginal

delivery of progesterone (1997). Foldvari et al. developed

interferon alpha liposomes for treating genital papilloma virus

infections. Pavelic et al. developed Lecithin liposomes of

Clotrimazole, metronidazole and chloramphenicol for treating

fungal infections; then tested for in-vitro stability in pre- and

post- menopausal environment, as well as for in-situ stability

in cow vaginal mucosa. In order to enhance stability, better

release characteristics and overall applicability of these drugs,

author incorporated these liposomes in bio-adhesive carbopol

hydrogels. In-vitro release testing performed in vaginal fluid

stimulant ensured controlled release of all three drugs (Pavelic

et al., 1999). Ning et al. also reported controlled release of

Clotrimazole from proliposomes for vaginal therapy. Poorly

soluble anti-fungal drug, Amphotericin B was successfully

administered in vagina when formulated as thermo-sensitive

gel of poloxamers 407 and 188 having drug-loaded cationic

liposomes (Kang et al., 2010). Curcumin, a well-known anti-

oxidant and anti-inflammatory agent when formulated in form

of liposomal gel against vaginal inflammation; overall anti-

inflammatory activity was significantly enhanced as revealed

by in-vitro studies (Basnet et al., 2012). Liposomal prepar-

ations loaded with anti-fungal agents are represented in

Table 8.

Vaginal micro-emulsions

In recent times, micro emulsion serves as an efficient

candidate for vaginal delivery of proteins, peptides and anti-

fungal drugs, because of their long term stability, ease of

preparation and high solubilization capacity. Micro-emulsion

based vaginal gel system has been efficiently used to deliver

different anti-fungal drugs as given in Table 9.

Vaginal bio-adhesive suppositories

Another novel approach towards successful vaginal delivery

is the concept of bio-adhesive suppositories. To deliver

anti-miotic agent, Clotrimazole into vagina, suppositories of

semi-synthetic solid triglycerides were prepared having bio-

adhesive polymers viz. polycarbophil, hydroxypropylmethyl-

cellulose and hyaluronic sodium salt. The author reported that

these polymer increased residence time of suppositories in

vagina by modifying adhesion force, liquefaction time and

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permanence of drug at expected site without any adverse

effect. The developed formulation showed controlled release

profile.

Vaginal bio-adhesive gel

A marketed bio-adhesive gel, Replens R of polycarbophil;

used to lubricate and to retain moisture of vagina. The

formulation maintains healthy acidic pH in vagina and

remains over there for 34 d (Lee et al., 1996; Hwang

et al., 1977). Another bio-adhesive gel named Prochieve TM

is used in hormonal replacement therapy. Later on, concept of

hydrogel was introduced which provides excellent controlled

release profile of most drugs. Hydrogels can be defined as a

three-dimensional, cross-linked hydrophilic polymeric net-

work which can absorb significant amount of water (Singh

et al., 2010). These are insoluble in water because of cross-

linked structure and can imbibe water up to 1020 times of its

molecular weight and become swollen (Kim et al., 1992;

Peppas et al., 2000). Hydrogel swells under the influence of

different stimuli-like temp, magnetic field, sound, electric

field, etc. and then drug releases from swelled hydrogel in

controlled manner (Garg et al., 2013). Different anti-fungal

drugs formulated in form of bioadhesive gel are given in

Table 10.

Vaginal micro particles (microspheres, microcapsules)

In the recent time, micro particles systems have also

employed for designing vaginal delivery system. With

addition of mucoadhesive polymers, these systems were

made bio-adhesive so as to gain intimate prolonged contact

with vaginal mucosa for controlled drug delivery (Garg et al.,

2012). Ketoconazole was formulated as bio-adhesive micro-

capsules and incorporated in tablet for vaginal delivery.

Dissolution studies of these microcapsules attest sustained

release of the drug. Different anti-fungal drugs formulated in

form of microparticles are given in Table 11.

Table 7. Vaginal bio-adhesive tablets loaded with anti-fungal agent.

Active drug Bio-adhesive polymer system Comments Reference

Clotrimazole Chitosan-Thioglycolic acid Conjugate(TGA)

The polymeric conjugates have 26-time longeradhesion time as compared to unmodifiedpolymer.

(Kast et al., 2002)

Econazole nitrate Carbopol 941/ NaCMC (1:1) Moderate swellingGood bio-adhesion for much longer durationRetarded release profile of the drug

(Ameen)

Clotrimazole Carbopol 934P/Sodium alginate (2:1)

Releases the drug for extended period of 24 hSignificant bio-adhesion property

(Sharma et al., 2006)

Ketoconazole(bio-adhesiveeffervescent tablet)

Carbopol 934P/ HPC (1:9) Excellent swelling,Controlled release of drug(95% for 24 h)In-vivo study in rats showed high vaginal

residence time (17% drug still retained after 24 h.)

(Wang & Tang, 2008)

Clotrimazole Mixture of NaCMC and HPMC Slowly released 72% of the drug over 12 h.Good swellingExcellent bio-adhesiveness

(Bhat & Shivakumar, 2010a)

Ketoconazoleeffervescent tablet

HPMC K4M: Chitosan (1:1)effervescent (sodium bicarbonateand citric acid at themole ratio of 3:1)

High in-vitro anti-fungal activityBio-adhesion time more than 12 hSustained release (more than 94% in 10 h.)

(Patel & Patel, 2010)

Sertaconazoleeffervescent tablet

Combination of HPMCK4M:Carbopol 934PEffervescent mixture (sodiumbicarbonate and citric acid at themole ratio of 3:1)

Controlled release (more than 80%) in 12 h.Excellent bio-adhesive strengthHigh in-vitro anti-fungal activity

(Patel et al., 2012)

Clotrimazole Combination Chitosan: HPMCK15 M(3:1)

Extended release profile( 98% for 30 h)Good bio-adhesive strengthGood swelling index

(Dangi et al., 2011)

Clotrimazole EudragitRL-100

Excellent in-vivo bio-adhesive strength and timeSustained release profile of 98% after 24 h.Excellent in-vitro anti-fungal activity

(Gupta et al., 2013)

Table 8. Anti-fungal agents formulated as vaginal liposomes.

Active drug Bioadhesive polymer system Comments Reference

Clotrimazole Carbopol Sustained release profileSignificant in-vivo activity in rats

(Ning et al., 2005)

Carbopol Controlled release was achievedHigh in-situ stability in cows vaginal mucosa

(Pavelic et al., 2001)

Amphotericin B Poloxamer 407 and 188 Good in-vitro anti-fungal activity (Kang et al., 2010)Metronidazole

(Elastic liposomes)Carbopol Controlled release for 24 h (Vanic et al., 2013)

Carbopol Controlled release was achievedHigh in-situ stability in cows vaginal mucosa

(Pavelic et al., 2001)

8 H. S. Johal et al. Drug Deliv, Early Online: 114

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Cyclodextrin in vaginal therapy

Cyclodextrin complexation was primarily used to increase

bioavailability of poorly soluble drugs by incorporating them

in cyclodextrin complexes (Patel & Rajesh). However, several

studies advocate the use of Cyclodextrin for improving

vaginal drug delivery. Hydroxypropyl-b-cyclodextrin formu-lation having Itraconazole was found to have good drug

Table 10. Bio-adhesive gel loaded with different anti-fungal agents.

Active Drug Delivery system Bioadhesive Polymer Comments Reference

Metronidazole Bio-adhesive gel Combination of chitosan andxanthan gum

Controlled release profileGood in-vitro anti-fungal activity

(Yellanki et al., 2010)

Bio-adhesive gel Combination of Xanthan gumand HPMC-K4M

Sustained release for 6 h.Excellent in-vitro anti-fungal

activity

(Ahmad et al., 2008)

Nonoxynol-9 Bio-adhesive gel Carbopol934P Initial high burst for 2min followedby sustained release for 7 h

(Lee et al., 1996)

Clotrimazole Bio-adhesive gel Combination of Xanthan gumand HPMC-K4M

Sustained release for 6 h.Good in-vitro anti-fungal activity

(Ahmad et al., 2008)

Itraconazole Thermo-sensitivevaginal gel

Poloxamer 407- HPMC Improved treatment of vaginalcandidiasis

(Karavana et al., 2012)

Miconazole nitrate Thermo-sensitivevaginal gel

PluronicF127, carbopol 934 and

polycarbophil

Sustained release for 12 h. (Hani & Shivakumar)

Miconazole nitrate Thermo-sensitive gel PEG-4000 Serves as controlled release carrier (Bhat & Shivakumar, 2010b)Clotrimazole Ion-sensitive gel Carbopol 934, HPMC and

sodium alginateExcellent in-vivo anti-fungal

activity in mice and zero orderrelease for 8 h

(Dhanaraj)

Clotrimazole:Cyclodextrin complex

Thermo-sensitive gel Pluronic F127- HPMC Sustained release for 92 h (Bilensoy et al., 2006)

Table 11. Different anti-fungal vaginal micro particle formulations.

Drug Formulation typeBio-adhesive

polymer Animal model Comments References

Clotrimazole Microspheres basedvaginal gel

Carbopol 934P. In-vitro Good control release pattern(99% in 12 h)

Higher bio-adhesion andretention time in vagina

Excellent in-vitro anti-fungalactivity

(Hani et al.)

Metronidazole Microencapsulatedbio-adhesive vaginal gel

Carbopol 974 In-vivoNew Zealand

rabbits

Extended release of drug(100% release for 36 h)

Formulation was non-irritant tovagina of New Zealand rabbits

Significant vaginal bio-adhesiontime

(Bhowmik et al., 2009)

Clotrimazole Spray dried microspheres asbio-adhesive vaginal tablet

Combination ofHPMC and

Carbopol

In-vitro Sufficient bio-adhesive strengthwith controlled release up to24 h

(Gupta et al., 2013)

Table 9. Micro-emulsion based vaginal gel loaded with anti-fungal agents.

Drug Formulation Bio-adhesive polymerAnimalmodel Comments References

Clotrimazole Micro emulsionbased vaginal gel

Carbopol ETD-2020 In-vitro High in-vitro bio-adhesion timeExcellent in-vitro anti-fungal

activity as compared tomarketed formulation

Controlled release profile of drug(more than 85% in 12 h.)

(Bachhav & Patravale, 2009)

Sertaconazole Micro emulsionbased vaginal gel

Carbopol 940 In-vitro Excellent anti-fungal activityGood bio-adhesive and

retention propertiesControlled release of 99% in 8 h.

(Patel & Patel, 2012)

Miconazole nitrate Micro emulsionbased gel

Polycarbophil In-vitro High bio-adhesive strengthExcellent in-vivo anti-fungal

activity in miceGood in-vitro anti-fungal activity

(Bhalekar et al., 2009)

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solubility and excellent mucoadhesive property. Vaginal

cream having Itraconazole complexed with b-cyclodextrinwas well tolerated and remained in vagina for several days.

Hydroxypropyl-b-cyclodextrin complex was reported toincrease solubility of Amphotericin B; when both were

formulated as thermo-sensitive, pH-sensitive gel, controlled

release was successfully achieved. Cyclodextrin complexes

were also successfully employed in anti-viral therapy to

deliver anti-HIV agents (Yang et al., 2008). Chang Yun et al

(2002) fabricated Clotrimazole-loaded cyclodextrin complex

by using combination of poloxamers (P) 407, 188, and

polycarbophil (PC). The results showed that controlled release

of drug was achieved and exhibit excellent in-vivo anti-fungal

activity in female rats (Yun Chang et al., 2002).

Other novel approaches against VC

With continuous use of anti-fungal agents for VC, subsequent

failure of therapy was observed. This is due to development of

resistant by Candida sp., so further prolongation of the

therapy will be ineffective. In spite of that, a new concept of

genetically engineered antibody was introduced, which suc-

cessfully encounter this limitation (Garg et al., 2011).

Different vaccines having modified antigens are introduced

that produce C. albicans specific antibodies that either have

fungicidal activity or inhibit adhesion of Candida to epithelial

cells as described in Table 12. Different techniques employed

for generating monoclonal antibodies are Hybridoma cell

production, Recombinant antibody engineering technique,

complementary-determining region (CDR) engraftment,

Cambridge Antibody Technology (CAT) (De St Groth &

Scheidegger, 1980), etc. Vaccine consists of diseases causing

micro-organism either in dead or partly killed form which will

stimulate immune system to recognize it as foreign microbe

and act against it by producing antibodies. Antibodies are

Y-shaped protein produced by plasma cells and utilized by

immune system to recognize and neutralize foreign particles

like bacteria or fungi. Monoclonal antibodies are the mono-

specific antibodies produced from single parent immune cell

by different techniques like hybridoma, recombinant tech-

nique, etc. Idiotypic is a shared characteristic of immuno-

globulin or T cell receptors (TCR). Idiotypic describes

distinctive sequence and region that makes any immunoglob-

ing/TCR unique from others of the same type which is its

variable region. Variable region has a specific amino-acid

sequence that determines its antigen binding affinity

and therefore the idiotope of the molecule. IgG or T cell

receptor having shared idiotope is the same idiotype

Table 12. Recently developed vaccines against VC.

Category/source AntigenAnimalmodel Underlying immunity Mechanism of action References

Subunits and glycoconjugates

65-kDa mannoprotein(MP65)

Rat Anti-MP65 antibodies Inhibit fungal adhesionto epithelial cellsmediated by MP65and SAP 2

(Sandini et al., 2007)

Secretory aspartylproteinase (SAP)2

Rat Anti- SAP 2 antibodies (De Bernardis et al., 2002,2007, 2012)

Recombinant N-teminusof Als 3p (rAls 3p)

Mice Anti- rAls 3p antibodies Inhibit fungal adhesionmediated by Als 3

(Spellberg et al., 2006)

Candida surfacemannan

Mice MAb B6 and MAb B6.1 Degrade b-1, 2-manno-triose (cell wallcomponent offungus)

(Han et al., 1998)

Octa-b- 1, 3-glucanepitope

Mice Serum and vaginal anti-b-glucan IgG antibodies

Degrade b-1, 2-manno-triose(cell wall componentof fungus)

(Torosantucci et al., 2005,2009; Pietrella et al., 2010)

Peptide Hepcidin 20 (Hep-20) In-vitro Antimicrobial activity Release b-glactosidasethat cleaveb-glycoside linkingin fungal cell wall

(Del Gaudio et al., 2013)

Idiotypes Killer-toxin neutralizingm Ab KT4

Rat Fungicidal antibodies Unknown (Polonelli et al., 1997)

Antibodies Mycograb (anti-Hsp-90antibodies)

Human Fungicidal Degrade Hsp-90 (cellwall component offungus)

(Pachl et al., 2006)

Antigen-pulsedcells

Dendritic cell pulsedwith Candida yeastsor yeast RNA

Mice Activation of T-helper 1 Immunity provided byIL-4,IL-6,IL-10,IL-12 P70

(Bacci et al., 2002)

Whole cell orcell extract

Heat killed Candidacells with novelmucosal adjuvantLT(R192G)

Mice Delayed hypersensitivityresponses and Increasedlevels ofImmunoglobulin G(IgG)

Release of cytokinesthat degrade fungalcells

(Cardenas-Freytag et al., 1999)

C. albicans Mannanextract- Bovineserum albuminconjugate

Mice IgG and IgM antibodies Degrade fungal cell wallmannan(mannoprotein)

(Han et al., 1999)

10 H. S. Johal et al. Drug Deliv, Early Online: 114

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(Miller et al., 1982). The main component of these vaccines

can be whole Candida cell or its cell extract, antibodies,

idiotypes, glycoconjugate and its subunits, human peptide,

antigen-pulsed cell, etc. Method for production these different

antigens are discussed below

Human Peptide Hepcidin 20: Human liver derivedHepticin-20 has a significant anti-fungal activity and is

either purchased or extracted from human source. This

peptide release b-glycosidase that cleaves b-Glycosidelinking in fungal cell wall.

Candida surface mannan complex: Candida surfacemannan was obtained by extracting yeast cell with

b-mercaptoethanol and then encapsulated in multilamil-lar liposomescomposed of phosphatidylcholine and chol-

esterol in ratio 3.2:1. After immunization antibodies

specific to b 1, 2-mannotriose (cell wall component ofCandida) is produced, and exerts their anti-fungal

activity (Han et al., 1998). This mannan extract may

complexed with Bovine serum albumin, and immuniza-

tion leads to production of IgG and IgM antibodies that

degrade Candida cell wall mannan (mannoprotein; Han

et al., 1999).

Dendritic cells pulsed with fungal RNA: Candida cellswere ruptured through repeated thawing and freezing on

liquid nitrogen. Hot extraction buffer (a 1:1 mixture of

phenol and 0.1 M LiCl, 100 mM Tris-HCl (pH 8), 10 mM

EDTA, and 1% SDS at 80 C) and then a mixture((24:1, v/v) of chloroform and isoamyl alcohol) was

added to the cells. Followed by centrifugation at

10 000 rpm at 4 C and water phase was mixed withequal volume of 4M lithium chloride. This mixture was

again centrifuged at 10 000 at 4 C and the RNA getsprecipitated. Obtained RNA pellet was dissolved in water

and precipitated using sodium acetate and ethanol at

20 C. Dendritic cells (DCs) were either extracted frombone-marrow of spleen. Spleen cells were subjected to

overnight plastic adherence to remove macrophages, then

reacted with 100 ml of anti-mouse CD11c mAbs (againstCD11c present on macrophage surface) conjugated with

Micro Beads followed by magnetic separation. Bone

marrow DCs, were obtained from femur of mice and

seeded for 6 d in six-well plates in 3 ml IMDM (Iscoves

Modified Dulbeccos Medium) with 10% FCS (fetal calf

serum), 50 mM 2-ME(2-mercaptoethanol), 50 mg/ml gen-tamicin sulfate, 2000 U/ml GM-CSF (granulocyte-macro-

phage colony-stimulating factor), and 1 103 U/ml IL-4.On day 3, non-adherent cells were replaced with mixture

of GM-CSF and interleukin-4. On day 6, DCs were

isolated from non-adherent cells and incubated at 37 Cfor 3 h. RNA (25 mg in 250 ml Opti-MEM medium) andDOTAP (50 mg in 250 ml Opti-MEM medium (minimumessential media)) was mixed in 12 75-mm polystyrenetubes and then 2 ml of it was added to DC and incubated

for 37 C for 24 h. IL-4 Immunization leads to activationof T-helper 1 thus initiating immune response against

Candida by releasing cytokines IL-4,IL-6,IL-10,IL-12

P70 (Bacci et al., 2002).

Human domain antibodies: A complex procedure wasadopted to yield Human domain antibodies against

virulent traits of Candida (De Bernardis et al., 2007).

In brief, the author uses genetically modified Antibody

variable domains (domain antibodies [DAbs]) that have

individual heavy-chain (VH) or k-chain (Vk) variable

domains and lacks the Fc region. From Phage expression

libraries, Human DAbs against 65-kDa mannoprotein

(MP65) or the secretory aspartyl proteinase (SAP)2 of

C. albicans (mono-specific DAbs) or against both fungal

antigens (heterodimeric, bispecific DAbs) were gener-

ated. A significant inhibition of fungal adherence

(mediated by MP65 and SAP)2) and complete clearance

of vaginal infection of fungus was observed using both

mono- and bi-specific DAbs in rat vagina.

B-glucan-conjugate vaccine for VC: Donatella et al.formulated b-glucan-conjugate in human compatibleMF59 adjuvant and anti-fungal activity was assessed in

murine model (Pietrella et al., 2010). The infection was

monitored using genetically engineered, luminescent

C. albicans strain and then Cfu was measured. The

mice were immunized with this conjugate and then a

prominent fall in Cfu of C. albicans was observed. This

anti-fungal activity was due to production of serum and

vaginal anti-b-glucan IgG antibodies. This antibodyrecognizes octa-b- 1, 3-glucan epitope which is presentin hyphal cell wall protein that mediates fungal adhesion

and invasion (Torosantucci et al., 2009). Then in-vivo

imaging techniques confirm excellent anti-fungal activ-

ity. Antonella et al. reported good protection against VC

in mice by formulating b-glucan (preparation from thebrown alga Laminaria digitata) conjugate with diphtheria

toxoid CRM197 (carrier protein). This conjugate pro-

duces anti-b-glucan IgG antibodies which provide pro-tection against Candida sp. (Torosantucci et al., 2005).

Recombinant ALS vaccine for VC: Ibrahim et al.developed vaccine of recombinant N-terminus of Als 1p

(rAls 1p) for protection of mice against disseminated and

mucosal candidiasis. The vaccine enhances cell-mediated

immunity rather than humoral and improves survival of

mice during candidiasis (Ibrahim et al., 2005). Latter on

they formulated another vaccine of recombinant

N-teminus of Als 3p (rAls 3p) against disseminated and

mucosal Candidiasis. The vaccine proved to as effective

as rAls 1p in disseminated Candidiasis and more effective

in Mucosal (vaginal) Candidiasis (Spellberg et al.,

2006).

Candida albicans mannan extractprotein conjugates:Vaccine having C. albicans Mannan (fungal cell wall

constituent) extract- Bovine serum albumin conjugate

was assessed for its anti-fungal activity in mice. The

vaccine was administered intraperitoneal (i.p) followed

by i.v. administration of viable Candida spp. Mice

developed both IgG and IgM antibodies specific for the

cell surface of Candida yeast cells and exerts its anti-

fungal activity (Han et al., 1999). Table 12 represents the

recently developed vaccines against VC.

Conclusion

Although much of research work has been done to deliver

anti-fungal drugs safely and effectively for VC, various

conventional dosage forms are available like creams, gel,

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suppositories, etc. But have numerous limitations like

systemic side-effects, lesser residence time, etc. To overcome

these limitations, a novel concept of bio-adhesive formula-

tions was introduced. While this delivery system successfully

encountered most of the disadvantages of conventional

dosage forms, but there continuous use has led to significant

resistance in Candida against azole agents. However now a

day, vaccines are employed for anti-fungal therapy and they

have been proved to be a good and potential alternative for

VC. But this delivery system still needs to be exploited, in

order to develop a novel, ideal, effective delivery system

against all Candida spp. and to protect and maintain integrity

of epithelial cells.

Acknowledgement

Authors Amit K Goyal (under IYBA scheme; BT/01/IYBA/

2009 dated 24/05/2010) thankful to Department of

Biotechnology (DBT), New Delhi, India.

Declaration of interest

The authors declare no conflicts of interests. The authors

alone are responsible for the content and writing of this

article.

References

Abrams L, Weintraub H. (1983). Disposition of radioactivity followingintravaginal administration of 3H-miconazole nitrate. Am J ObstetrGynecol 147:9701.

Abruquah H. (2012). Prevalence and antifungal susceptibility of Candidaspecies isolated from women attending a gynaecological clinic inKumasi, Ghana. J Sci Technol (Ghana) 32:3945.

Ahmad FJ, Alam MA, Khan ZI, et al. (2008). Development and in vitroevaluation of an acid buffering bioadhesive vaginal gel for mixedvaginal infections. Acta pharmaceutica 58:40719.

Alexander NJ, Baker E, Kaptein M, et al. (2004). Why consider vaginaldrug administration? Fertil Steril 82:112.

Alli J, Okonko I, Odu N, et al. (2011). Detection and prevalence ofCandida isolates among patients in Ibadan, Southwestern Nigeria.J Microbiol Biotechnol Res 1(3):176184.

Ameen DW. (2011). Development and in vitro evaluation of bioadhesivevaginal tablet using econazole nitrate as a model drug. Iraqi JPharmaceut Sci 57:5765.

Bacci A, Montagnoli C, Perruccio K, et al. (2002). Dendritic cells pulsedwith fungal RNA induce protective immunity to Candida albicans inhematopoietic transplantation. J Immunol 168:290413.

Bachhav YG, Patravale VB. (2009). Microemulsion-based vaginal gel ofclotrimazole: formulation, in vitro evaluation, and stability studies.AAPS PharmSciTech 10:47681.

Basnet P, Hussain H, Tho I, et al. (2012). Liposomal delivery systemenhances anti-inflammatory properties of curcumin. J Pharmaceut Sci101:598609.

Bhalekar MR, Pokharkar V, Madgulkar A, et al. (2009). Preparation andevaluation of miconazole nitrate-loaded solid lipid nanoparticles fortopical delivery. AAPS PharmSciTech 10:28996.

Bhat S, Shivakumar H. (2010a). Bioadhesive controlled releaseclotrimazole vaginal tablets. Trop J Pharmaceut Res 9(4): 33946.

Bhat SR, Shivakumar HG. (2010b). Formulation development andevaluation of thermosensitive gel for vaginal drug delivery. Latin AmJ Pharm 29(7): 10939.

Bhowmik BB, Nayak BS, Chatterjee A. (2009). Formulation develop-ment and characterization of metronidazole microencapsulatedbioadhesive vaginal gel. Int J Pharm Pharm Sci 1:24057.

Bilensoy E, Rouf MA, Vural I, et al. (2006). Mucoadhesive,thermosensitive, prolonged-release vaginal gel for clotrimazole:b-cyclodextrin complex. AAPS PharmSciTech 7:E5460.

Brannon-Peppas L. (1993). Novel vaginal drug release applications.Adv Drug Deliv Rev 11:16977.

Cardenas-Freytag L, Cheng E, Mayeux P, et al. (1999). Effectiveness of avaccine composed of heat-killed Candida albicans and a novelmucosal adjuvant, LT (R192G), against systemic candidiasis. InfectImmun 67:82633.

Carr PL, Felsenstein D, Friedman RH. (1998). Evaluation and manage-ment of vaginitis. J Gen Intern Med 13:33546.

Cejtin HE, Mason ED. (2000). A guide to the diagnosis and treatment ofvaginitis and cervicitis. Hosp Phys 5363.

Choudhury A, Das S, Kar M. (2011). A review on noveltyand potentiality of vaginal drug delivery. Int J PharmTech Res 3:103344.

D Amati G, Di Gioia C, Pannunzi LP, et al. (2003). Functional anatomyof the human vagina. J Endocrinol Investig 26:926.

Dangi AA, Sheth NR, Patel H, et al. (2011). Formulation and evaluationof once daily mucoadhesive vaginal tablet of clotrimazoleusing natural and synthetic polymers. Asian J. Pharm. Health Sci 1:17682.

De Bernardis F, Amacker M, Arancia S, et al. (2012). A virosomalvaccine against candidal vaginitis: immunogenicity, efficacy andsafety profile in animal models. Vaccine 30:44908.

De Bernardis F, Boccanera M, Adriani D, et al. (2002). Intravaginal andintranasal immunizations are equally effective in inducing vaginalantibodies and conferring protection against vaginal candidiasis.Infect Immun 70:27259.

De Bernardis F, Liu H, OMahony R, et al. (2007). Human domainantibodies against virulence traits of Candida albicans inhibit fungusadherence to vaginal epithelium and protect against experimentalvaginal candidiasis. J Infect Dis 195:14957.

De Blaey C, Polderman J. (1980). Rationales in the design of rectal andvaginal delivery forms of drugs. Drug Design 9:23766.

De St Groth SF, Scheidegger D. (1980). Production of monoclonalantibodies: strategy and tactics. J Immunol Meth 35:121.

Del Gaudio G, Lombardi L, Maisetta G, et al. (2013). Antifungal activityof the noncytotoxic human peptide hepcidin 20 against fluconazole-resistant Candida glabrata in human vaginal fluid. Antimicrob AgentsChemotherap 57:431421.

Dhanaraj A, Jaya Raja Kumar, Jayachandran K, et al. (2013).Development and in vitro/in vivo evalution of tripolymers basedclotrimazole in situ gel for oral thrush. Journal of pharmaceuticalscience and technology 3(10):98595.

Dias LB, Melhem MDSC, Szeszs MW, et al. (2011). Vulvovaginalcandidiasis in Mato Grosso, Brazil: pregnancy status, causativespecies and drugs tests. Brazil J Microbiol 42:13007.

El-Din S, Reynolds M, Ashbee H, et al. (2001). An investigation into thepathogenesis of vulvo-vaginal candidosis. Sex Trans Infect 77:17983.

Ernest J. (1992). Topical antifungal agents. Obstetr Gynecol Clin N Am19:587607.

Faraji R, Rahimi MA, Assarehzadegan M. (2012). Prevalence of vaginalcandidiasis infection in women referred to Kermanshah hygieniccenters, Iran in 2010. Life Sci J 6:22738.

Faro S. (1994). Systemic vs. topical therapy for the treatment ofvulvovaginal candidiasis. Infect Dis Obstetr Gynecol 1:2028.

Fong I. (1992). The value of chronic suppressive therapy withitraconazole versus clotrimazole in women with recurrent vaginalcandidiasis. Genitourinary Med 68:3747.

Francois M, Snoeckx E, Putteman P, et al. (2003). A mucoadhesive,cyclodextrin-based vaginal cream formulation of itraconazole.Aaps Pharmsci 5:504.

Gagandeep GT, Malik B, Rath G, Goyal AK. (2014). Development andcharacterization of nano-fiber patch for the treatment of glaucoma.Eur J Pharm Sci 53:106.

Garg T, Bilandi A, Kapoor B. (2011). Scaffold: tissue engineering andregenerative medicine. Int Res J Pharm 2:3742.

Garg T, Goyal AK. (2012). Iontophoresis: drug delivery system byapplying an electrical potential across the skin. Drug Deliv Lett 2:27080.

Garg T, Goyal AK. (2014a). Biomaterial-based scaffolds - current statusand future directions. Expert Opin Drug Deliv 11:76789.

Garg T, Goyal AK. (2014b). Liposomes: targeted and controlled deliverysystem. Drug Deliv Lett 4:6271.

Garg T, Rath G, Goyal AK. (2014a). Comprehensive review on additivesof topical dosage forms for drug delivery. Drug Deliv.

Garg T, Rath G, Goyal AK. (2014b). Novel technology to improve drugloading in polymeric nanofibers. Drug Deliv Lett 4:7986.

12 H. S. Johal et al. Drug Deliv, Early Online: 114

Dru

g D

eliv

ery

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Lav

al o

n 06

/28/

14Fo

r per

sona

l use

onl

y.

Garg T, Singh O, Arora S, Murthy R. (2012). Scaffold: a novel carrier forcell and drug delivery. Crit Rev Ther Drug Carrier Syst 29:163.

Garg T, Singh S, Goyal AK. (2013). Stimuli-sensitive hydrogels: anexcellent carrier for drug and cell delivery. Crit Rev Ther Drug CarrierSyst 30:369409.

Gearhart MO. (1994). Worsening of liver function with fluconazole andreview of azole antifungal hepatotoxicity. Ann Pharmacother 28:117781.

Goyal G, Garg T, Malik B, et al. (2013). Development and character-ization of niosomal gel for topical delivery of benzoyl peroxide. DrugDeliv.

Gupta NV, Natasha S, Getyala A, Bhat RS. (2013). Bioadhesivevaginal tablets containing spray dried microspheres loaded withclotrimazole for treatment of vaginal Candidiasis. Acta Pharmaceutica63:35972.

Haas TA, Plow EF. (1994). Integrin-ligarid interactions: a year in review.Curr Opin Cell Biol 6:65662.

Han Y, Morrison RP, Cutler JE. (1998). A vaccine and monoclonalantibodies that enhance mouse resistance to Candida albicans vaginalinfection. Infect Immun 66:57716.

Han Y, Ulrich MA, Cutler JE. (1999). Candida albicans mannanextractprotein conjugates induce a protective immune responseagainst experimental candidiasis. J Infect Dis 179:147784.

Hani U, Shivakumar H. (2013). Development of miconazole nitratethermosensitive bioadhesive vaignal gel for vaginal candidiasis.American Journal of Advanced Drug Delivery 3:358368.

Hani U, Shivakumar H, Gowrav M. (2014). Formulation design andevaluation of a novel vaginal delivery system of clotrimazole.International Journal of Pharmaceutical Science and Research 5(1):22027.

Hay RJ. (1993). Risk/benefit ratio of modern antifungal therapy: focuson hepatic reactions. J Am Acad Dermatol 29:S504.

Hussain A, Ahsan F. (2005). The vagina as a route for systemic drugdelivery. J Control Rel 103:30113.

Hwang S, Owada E, Suhardja L, et al. (1977). Systems approach tovaginal delivery of drugs IV: methodology for determination ofmembrane surface pH. J Pharmaceut Sci 66:77881.

Hwang S, Owada E, Yotsuyanagi T, et al. (1976). Systems approach tovaginal delivery of drugs II: in situ vaginal absorption of unbranchedaliphatic alcohols. J Pharmaceut Sci 65:157478.

Ibrahim AS, Spellberg BJ, Avenissian V, et al. (2005). Vaccination withrecombinant N-terminal domain of Als1p improves survival duringmurine disseminated candidiasis by enhancing cell-mediated, nothumoral, immunity. Infect Immun 73:9991005.

Jain SK, Singh R, Sahu B. (1997). Development of a liposome basedcontraceptive system for intravaginal administration of progesterone.Drug Dev Indust Pharm 23:82730.

Jindal N, Gill P, Aggarwal A. (2007). An epidemiological study ofvulvovaginal candidiasis in women of childbearing age. Ind J MedMicrobiol 25:175.

Johnson T, Greer I, Kelly R, Calder A. (1992). The effect of pH onrelease of PGE2 from vaginal and endocervical preparations forinduction of labour: an in-vitro study. BJOG: An Int J Obstetr &Gynaecol 99:87780.

Jouault T, El Abed-El Behi M, Martnez-Esparza M, et al. (2006).Specific recognition of Candida albicans by macrophages requiresgalectin-3 to discriminate Saccharomyces cerevisiae and needsassociation with TLR2 for signaling. J Immunol 177:467987.

Jyotsana M, Sagar B, Mahesh D. (2010). Mucosal drug delivery system.IJRAP 1:637.

Kang J-W, Davaa E, Kim Y-T, Park J-S. (2010). A new vaginal deliverysystem of amphotericin B: a dispersion of cationic liposomes in athermosensitive gel. J Drug Target 18:63744.

Karavana SY, Rencber S, Senyigit ZA, Baloglu E. (2012). A new in-situgel formulation of itraconazole for vaginal administration. PharmacolPharm 3(4):41726.

Kast CE, Valenta C, Leopold M, Bernkop-Schnurch A. (2002). Designand in vitro evaluation of a novel bioadhesive vaginal drug deliverysystem for clotrimazole. J Control Rel 81:34754.

Kataria K, Garg T, Goyal AK, Rath G. (2014). Novel technology toimprove drug loading in polymeric nanofibers. Drug Deliv Lett 4:7986.

Katz DF, Dunmire EN. (1993). Cervical mucus: problems andopportunities for drug delivery via the vagina and cervix. Adv DrugDeliv Rev 11:385401.

Kaur M, Garg T, Rath G, Goyal AK. (2014). Current nanotechnologicalstrategies for effective delivery of bioactive drug molecules in thetreatment of tuberculosis. Crit Rev Ther Drug Carrier Syst 31:4988.

Khan F, Baqai R. (2010). In vitro antifungal sensitivity of fluconazole,clotrimazole and nystatin against vaginal candidiasis in females ofchildbearing age. J Ayub Med Coll Abbottabad 22:197200.

Kim SW, Bae YH, Okano T. (1992). Hydrogels: swelling, drug loading,and release. Pharmaceut Res 9:28390.

Lee CH, Anderson M, Chien YW. (1996). Characterization of in-vitrospermicidal activity of chelating agent against human sperm.J Pharmaceut Sci 85:64954.

Lee V. (1990). Peptide and protein drug delivery. Boca Raton, FL: CRCPress.

Liu Y, Filler SG. (2011). Candida albicans Als3, a multifunctionaladhesin and invasin. Eukaryotic Cell 10:16873.

Loza L, Fu Y, Ibrahim AS, et al. (2004). Functional analysis of theCandida albicans ALS1 gene product. Yeast 21:47382.

Masters WH, Johnson VE. (1966). Human sexual response. Boston(MA): Little, Brown & Co.

Mathiowitz E, Chickering III DE, Lehr C-M. (2013). Bioadhesive drugdelivery systems: fundamentals, novel approaches, and development.Boca Raton, FL: CRC Press.

Mcgregor JA, Ismail M, Mccormack WM. (1998). A pilot study ofmetronidazole vaginal gel versus oral metronidazole for the treatmentof Trichomonas vaginalis vaginitis. Sex Trans Dis 25:1769.

Miller RA, Maloney DG, Warnke R, Levy R. (1982). Treatment of B-celllymphoma with monoclonal anti-idiotype antibody. New Engl J Med306:51722.

Newson L. (2013). Management of vulvovaginal infections in primarycare part 1: Candidiasis. Br J Fam Med 1:3.

Ning M, Guo Y, Pan H, et al. (2005). Preparation, in vitro and in vivoevaluation of liposomal/niosomal gel delivery systems for clotrim-azole. Drug Dev Industr Pharm 31:37583.

Novak A, De La Loge C, Abetz L, Van Der Meulen E. (2003). Thecombined contraceptive vaginal ring, NuvaRing: an internationalstudy of user acceptability. Contraception 67:18794.

Ogunshe AA, Lawal OA, Iheakanwa CI. (2008). Effects of SimulatedPreparations of Plants used in Nigerian Traditional Medicine onCandida spp. Associated with Vaginal Candidiasis. Ethnobot ResAppl 6:37383.

Owen DH, Dunmire EN, Plenys AM, Katz DF. (1999). Factorsinfluencing nonoxynol-9 permeation and bioactivity in cervicalmucus. J Control Rel 60:2334.

Paavonen J. (1982). Physiology and ecology of the vagina. Scandi JInfect Dis. Suppl 40:315.

Pachl J, Svoboda P, Jacobs F, et al. (2006). A randomized, blinded,multicenter trial of lipid-associated amphotericin B alone versusin combination with an antibody-based inhibitor of heat shockprotein 90 in patients with invasive candidiasis. Clin Infect Dis 42:140413.

Parnami N, Garg T, Rath G, Goyal AK. (2013). Development andcharacterization of nanocarriers for topical treatment of psoriasis byusing combination therapy. Artif Cells Nanomed Biotechnol.

Patel A, Patel J. (2012). Mucoadhesive microemulsion based prolongedrelease vaginal gel for anti-fungal drug. Am J PharmTech Res 2:64961.

Patel A, Patel K, Patel J. (2012). Design, development and in vitroevaluation of sertaconazole mucoadhesive vaginal tablet. DerPharmacia Lettre 4:41827.

Patel GM, Patel AP. (2010). A novel effervescent bioadhesivevaginal tablet of ketoconazole: formulation and invitro evaluation.Int J PharmTech Res 2(1):656.

Patel N, Rajesh K. (2014). Ophthalmic in situ gel. Pharmagene 1:2933.Pavelic Z, Skalko-basnet N, Jalsenjak I. (1999). Liposomes containing

drugs for treatment of vaginal infections. Eur J Pharmaceut Sci 8:34551.

Pavelic Z, Skalko-Basnet N, Schubert R. (2001). Liposomal gels forvaginal drug delivery. Int J Pharmaceut 219:13949.

Peppas N, Bures P, Leobandung W, Ichikawa H. (2000). Hydrogels inpharmaceutical formulations. Eur J Pharmaceut Biopharmaceut 50:2746.

Pietrella D, Rachini A, Torosantucci A, et al. (2010). A b-glucan-conju-gate vaccine and anti-b-glucan antibodies are effective against murinevaginal candidiasis as assessed by a novel in vivo imaging technique.Vaccine 28:171725.

DOI: 10.3109/10717544.2014.928760 Drug delivery system for vaginal candidiasis 13

Dru

g D

eliv

ery

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Lav

al o

n 06

/28/

14Fo

r per

sona

l use

onl

y.

Pirotta MV, Garland SM. (2006). Genital Candida species detected insamples from women in Melbourne, Australia, before and aftertreatment with antibiotics. J Clin Microbiol 44:321317.

Polonelli L, Seguy N, Conti S, et al. (1997). Monoclonal yeast killertoxin-like candidacidal anti-idiotypic antibodies. Clin Diagnos LabImmunol 4:1426.

Rauceo JM, De Armond R, Otoo H, et al. (2006). Threonine-rich repeatsincrease fibronectin binding in the Candida albicans adhesin Als5p.Eukaryotic Cell 5:166473.

Richter SS, Galask RP, Messer SA, et al. (2005). Antifungalsusceptibilities of Candida species causing vulvovaginitis andepidemiology of recurrent cases. J Clin Microbiol 43:215562.

Robinson JR, Bologna WJ. (1994). Vaginal and reproductivesystem treatments using a bioadhesive polymer. J Control Rel28:8794.

Sandini S, La Valle R, De Bernardis F, et al. (2007). The 65 kDamannoprotein gene of Candida albicans encodes a putativeb-glucanase adhesin required for hyphal morphogenesis and experi-mental pathogenicity. Cell Microbiol 9:122338.

Santoni G, Spreghini E, Lucciarini R, et al. (2001). Involvement of avb3integrin-like receptor and glycosaminoglycans in Candida albicansgerm tube adhesion to vitronectin and to a human endothelial cell line.Microbial Pathogen 31:15972.

Shafik SA, Hassan YM, Eldin AK. (2007). Vaginal candidiasis:incidence, etiology and pathogenesis. JASMR 2:11527.

Sharma G, Jain S, Tiwari A, Kaur G. (2006). Once daily bioadhesivevaginal clotrimazole tablets: design and evaluation. ActaPharmaceutica-Zagreb- 56:337.

Singh A, Sharma PK, Garg VK, Garg G. (2010). Hydrogels: a review.Int J Pharmaceut Sci Rev Res 4(2): 97105.

Singh H, Sharma R, Joshi M, et al. (2014). Transmucosal delivery ofDocetaxel by mucoadhesive polymeric nanofibers. Artif CellsNanomed Biotechnol.

Sjoberg I, Cajander S, Rylander E. (1988). Morphometric characteristicsof the vaginal epithelium during the menstrual cycle. Gynecol ObstetrInvest 26:13644.

Sobel JD, Brooker D, Stein GE, et al. (1995). Single oral dosefluconazole compared with conventional clotrimazole topicaltherapy of Candida vaginitis. Am J Obstetr Gynecol 172:12638.

Sobel JD, Wiesenfeld HC, Martens M, et al. (2004). Maintenancefluconazole therapy for recurrent vulvovaginal candidiasis. N Engl JMed 351:87683.

Song Y, Wang Y, Thakur R, et al. (2004). Mucosal drug delivery:membranes, methodologies, and applications. Crit Rev TherapeutDrug Carrier Syst 21(3): 195256.

Spellberg BJ, Ibrahim AS, Avanesian V, et al. (2006). Efficacy of theanti-Candida rAls3p-N or rAls1p-N vaccines against disseminated andmucosal candidiasis. J Infect Dis 194:25660.

Spreghini E, Gismondi A, Piccoli M, Santoni G. (1999). Evidence foravb3 and avb5 integrin-like vitronectin (VN) receptors in Candidaalbicans and their involvement in yeast cell adhesion to VN. J InfectDis 180:15666.

Stein GE, Gurwith D, Mummaw N, Gurwith M. (1986). Single-dosetioconazole compared with 3-day clotrimazole treatment in vulvova-ginal candidiasis. Antimicrob Agents Chemother 29:96971.

Stein GE, Mummaw N. (1993). Placebo-controlled trial of itraconazolefor treatment of acute vaginal candidiasis. Antimicrob AgentsChemother 37:8992.

Stewart-Tull D. (1964). Evidence that vaginal lactobacilli do not fermentglycogen. Am J Obstetr Gynecol 88:676.

Syed TS, Braverman PK. (2004). Vaginitis in adolescents. Adolesc MedClin 15:23551.

Torosantucci A, Bromuro C, Chiani P, et al. (2005). A novel glyco-conjugate vaccine against fungal pathogens. J Exp Med 202:597606.

Torosantucci A, Chiani P, Bromuro C, et al. (2009). Protection by anti-b-glucan antibodies is associated with restricted b-1, 3 glucan bindingspecificity and inhibition of fungal growth and adherence. PLoS One4:e5392.

Vanic Z, Hafner A, Bego M, Skalko-basnet N. (2013). Characterizationof various deformable liposomes with metronidazole. Drug Dev IndusPharm 39:4818.

Vermesh M, Fossum GT, Kletzky OA. (1988). Vaginal bromocriptine:pharmacology and effect on serum prolactin in normal women.Obstetr Gynecol 72:6938.

Vermitsky J-P, Self MJ, Chadwick SG, et al. (2008). Survey of vaginal-flora Candida species isolates from women of different age groups byuse of species-specific PCR detection. J Clin Microbiol 46:15013.

Vukovich R, Heald A, Darragh A. Vaginal absorption of 2 imidazoleantifungal agents, econazole and miconazole. Clinical pharmacology& therapeutics. St Louis (MO): Westline Industrial DR, Mosby-YearBook INC. 11830;1977:12121.

Wang L, Tang X. (2008). A novel ketoconazole bioadhesive effervescenttablet for vaginal delivery: design, in vitro and in vivoevaluation.Int J Pharmaceut 350:1817.

Washington N, Washington C, Wilson C. (2000). Physiologicalpharmaceutics: barriers to drug absorption. Boca Raton, FL: CRCPress.

Watson C, Pirotta M. (2011). Recurrent vulvovaginal candidiasis: currentmanagement. Austral Fam Phys 40:149.

Woolfson AD, Malcolm RK, Gallagher R. (2000). Drug delivery by theintravaginal route. Crit Rev Therapeut Drug Carrier Syst 17(5):50955.

Yamashita A, Oshima S, Matsuo K, et al. (1991). [Pharmacologicalstudies of intravaginally applied dehydroepiandrosterone sulfate(DHA-S)]. Nihon yakurigaku zasshi. Folia Pharmacologica Japonica98:319.

Yang H, Parniak MA, Isaacs CE, et al. (2008). Characterization ofcyclodextrin inclusion complexes of the anti-HIV non-nucleosidereverse transcriptase inhibitor UC781. AAPS J 10:60613.

Yellanki SK, Goranti S, Deb SK. (2010). Development of metronidazoleintravaginal gel for the treatment of bacterial vaginosis: effect ofmucoadhesive natural polymers on the release of metronidazole. Int JPharmTech Res 2(3): 174650.

Yun Chang J, Oh Y-K, Soo Kong H, et al. (2002). Prolonged antifungaleffects of clotrimazole-containing mucoadhesive thermosensitive gelson vaginitis. J Control Rel 82:3950.

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Advanced topical drug delivery system for the management of vaginal candidiasisIntroductionPathophysiology of vaginal candidiasisPrevalence of vaginal candidiasisFactor affecting vaginal drug absorption (Stewart-Tull, 1964;Hussain &Ahsan, 2005;Mathiowitz etal., 2013)Available therapies for vaginal candidiasisConventional topical intravaginal delivery systemsNovel approaches in vaginal formulationsConclusionAcknowledgementDeclaration of interestReferences

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