Comparing the Effect of Garlic, Zataria multiflora and Clotrimazole Vaginal Cream 2% on Improvement of Fungal Vaginitis: A Randomized Controlled Trial

AUTHORS

Azizeh Farshbaf-Khalili 1 , Behnam Mohammadi-Ghalehbin 2 , Mahnaz Shahnazi 1 , Soltan Asghari 1 , * , Yusef Javadzadeh 3 , Payman Azghani 4

1 Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, IR Iran

2 Department of Microbiology and Parasitology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran

3 Faculty of Pharmacology, Tabriz University of Medical Sciences, Tabriz, IR Iran

4 Department of Microbiology and Parasitology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran

How to Cite: Farshbaf-Khalili A, Mohammadi-Ghalehbin B, Shahnazi M, Asghari S, Javadzadeh Y, et al. Comparing the Effect of Garlic, Zataria multiflora and Clotrimazole Vaginal Cream 2% on Improvement of Fungal Vaginitis: A Randomized Controlled Trial, Iran Red Crescent Med J. 2016 ; 18(12):e29262. doi: 10.5812/ircmj.29262.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 18 (12); e29262
Published Online: August 17, 2016
Article Type: Research Article
Received: April 25, 2015
Revised: May 30, 2015
Accepted: June 22, 2015
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Abstract

Background: Garlic and Zataria multiflora boiss (ZMB) are herbal medicines used traditionally in the treatment of infections, including candidal vaginitis.

Objectives: This study aimed to examine the effect of garlic and ZMB vaginal cream 2%, in the treatment and recurrence of candidal vaginitis.

Methods: This randomized, double-blinded clinical trial was conducted on 240 married women with candidal vaginitis. The patients used 5 gr garlic, ZMB or clotrimazole vaginal cream 2% daily, for 7 days. Complaints of the patients, clinical observations and laboratory parameters were recorded before treatment, on days 7 and 30, after treatment. The data were analyzed by SPSS v. 21 through chi-square, Fisher, ANOVA with repeated measures, McNemar and Kruskal-Wallis tests. A P <0.05 was considered significant.

Results: Before treatment, all patients had positive candidiasis fungi culture, in both groups (100%). The positive culture was 14.1%, 15.2%, 10.3%, respectively, on day 7 after treatment and 2.6%, 0%, 0% on day 30, after treatment with garlic, ZMB and clotrimazole, respectively (P < 0.001). No significant differences were observed between groups on days 7 (P = 0.69) and 30 (P = 0.21) after treatment, in culture results. There were no significant differences between groups, in terms of patient complaints and clinical observations before intervention, at days 7 and 30 after treatment (P > 0.05). Mean scores of candidal symptoms reduced significantly in all groups at on 7 and 30, after treatment (P < 0.001).

Conclusions: Garlic and ZMB vaginal cream 2% can be used as an effective treatment option in cases of drug resistance and, also, by the people who are interested in treating with herbal medicines.

Keywords

Vaginitis Candidiasis Garlic Clotrimazole Herbal Medicine

Copyright © 2016, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Candidal vaginitis is the second most common vaginal infection (1, 2). Studies conducted in Iran have shown that 41.3% of women have had vaginal infections and the most common cause of vaginitis was candida (47.4%) (3). Since this infection causes problems such as depression, low self-esteem, life dissatisfaction, increased stress and decreased sexual relations in women, it is therefore necessary to begin treatment early (4).

There are several treatments for candidal vaginitis, including drugs like topical and oral azoles (5). The success of the treatment with these drugs is almost 80% (6). Oral azole drugs have several side effects, such as dizziness, nausea, vomiting, abdominal pain, diarrhea and headache and are mostly contraindicated during pregnancy and lactation (7, 8). A certain degree of drug resistance has been recently reported (9-11).

According to the side effects of the chemical drugs, consumption of herbal drugs has been common (12). In several studies it has been observed that many plants contain substances that have effect on bacteria, viruses and fungi (13). Among these, garlic is one of the oldest drugs used to treat various diseases. Active ingredients of garlic include alliine, allicine and derivatives of allicine, as ajoene and dithiin (14).

Micosin vaginal cream (50 grams), containing extracts of garlic 1: 1000 and Zataria multifloraboiss (ZMB) is available on the Iran market (15). In Ardebil, this herbal plant is used in different forms to treat different types of diseases, such as vaginitis, and most people are satisfied with its use (13).

The ZMB is a type of mint family (Lamiaceae). The essential oil contains 25-40% phenol, with considerable amounts of thymol and a small amount of carvacrol. Other compounds include parasmin, bornyl, linalool and β-pinene. The thymol and carvacrol of ZMB have antifungal (Candida) effect (16). In Iran, ZMB vaginal cream is produced based on 0.027-0.033% thymol, branded as Leucorex, by Bariji Essence Company and it has antibacterial and candidiasis effects (17). It is traditionally used to treat vaginal infections. If consumed in small amounts, these medicinal herbs have no side effects (18). A clinical study by Fouladi et al. showed that the effects of the ZMB (1%) vaginal cream are similar to clotrimazole (19). In the study of Kordi et al., the effects of vaginal garlic extract (1%) douche was inferior to clotrimazole cream 1% (20). Bahadoran et al. indicated that the effects of vaginal cream containing garlic (1: 1000) and thyme are similar to clotrimazole (21). In the study of Fardyazar et al., the response to treatment and reduction in recurrence rate of vulvovaginal candidiasis were similar among fluconazole and long-term users of azole vaginal creams (22). Goncagul et al. indicated that garlic and ZMB act against bacterial, viral, mycotic and parasitic infections. It is also known that garlic is a wonderful plant, having the properties of empowering immune system, anti-tumor and antioxidant effects (13). In the study of Jafari et al., ZMB essence, at concentrations of 50 and 25 mg/mL, effectively removed Candida cells that had adhered to the denture surface, similar to the level of removal observed for 100000 IU nystatin (23).

2. Objectives

Since there are no clinical studies, which compare the effects of the three therapies of garlic, ZMB and clotrimazole, simultaneously, while, on the other hand, we did not find any clinical study to survey the effect of garlic 2% and ZMB 2% and there is a great amount of inconsistency between the results of existing trials, the present study aimed to compare the effect of the garlic 2%, ZMB 2% and clotrimazole 2% vaginal cream in the treatment and recurrence of candidal vaginitis.

3. Methods

The present research is a double blind clinical trial that was performed on 240 patients referred to Ardabil Alavi governmental and referral hospital center, Ardabil, Iran, from October 2013 to January 2014. The research was registered with code IRCT201305276709N12 in IRCT and approved by the Regional Ethics Committee of Tabriz University of Medical Sciences (9253), Tabriz, Iran. Inclusion criteria consisted of married women aged 18 - 49 years, who had candidal vaginitis, accessibility to telephone and were literate. Exclusion criteria included use of immunosuppressive drugs, antibiotics, vaginal medications during the past 2 weeks, the risk of autoimmune diseases, breast feeding, pregnancy, chronic diseases and hypothyroidism, organ transplantation, Gardnerella vaginalis, Trichomonas vaginalis, post-menopausal women, history of abortion or childbirth less than 6 weeks, history of chronic candidiasis, allergy to clotrimazole.

Data collection instruments included socio-demographic and fertility characteristics, patient complaints and clinical observations and laboratory tests. The socio-demographic and fertility characteristics questionnaire included age, education level, occupation, number of pregnancies, abortions, currently used contraception methods of patients.

The validity was determined as content validity. A researcher and coresearcher examined separately the vaginal discharge of 10 patients, to determine the reliability. In this study, the Spearman correlation coefficient was measured as r = 0.835. Also, among 10 patients, two samples were prepared separately and were sent to the laboratory under two different names, to verify the similarity of the results.

We used Tomy SX-700e autoclave (Tomy Seiko Co. Ltd., Tokyo, Japan) to autoclave culture. Sabouraud dextrose agar with chloramphenicol was used to prepare cultivation. Olympus CXZ1FS1 microscope (Tokyo, Japan) was applied for visual identification of Candida in vaginal discharge. We used SANY laboratory incubator Netherlands 120, nl4879 for Candida growth for 48 hours, at an ambient temperature of 30°C.

Sample size was considered 80 patients in each group, after comparison of the ratios and assuming α = 0.05, β = 20% and taking into consideration the recovery rate in Fuladi et al. study, in the group receiving clotrimazole 47.4%, in the group receiving ZMB 54.3%, and in Kordy et al. study the group receiving clotrimazole 57% and the group receiving garlic 34%, by considering the loss of 10% of participants (19, 20). Then we used the larger calculated samples.

Equation 1.

The women who complained from vulvovaginal pruritus and discharge completed the questionnaire of demographic and fertility characteristics, complaints of patients and severity of disease, through the interview, after a full explanation of the objectives and methodology. Informed consent was obtained before the completion of questionnaires. Each symptom (cheesy discharge, pruritus, edema, erythema, irritation during intercourse, pain during intercourse) was scored between 0 and 3, based on severity for determination of the infection level, as follows: (0 - 2) = no, (3 - 8) = mild, (9 - 13) = medium, (14 - 18) = severe. The patients should obtain a minimum score of 3, out of 18, to be eligible for the study.

In patients with signs of candidiasis, vaginal discharge samples were taken from the posterior fornix, by three sterile swabs. The discharges on the first swab specimens were placed on a clean slide for whiff testing, then one or two drops of potassium hydroxide 10% were added, being examined afterward regarding the amine odor and studied under a microscopic slide in the presence of yeast cells. The second swab discharges were placed in a test tube containing 1 mL normal saline for wet mount test and gram staining, for observing clue cells and Trichomonas. The third swab was hold in sabouraud dextrose agar chloramphenicol, for fungal cultures, for 48 h at 30°C and, in the case of growth of the fungus in the dextrose agar plate, the culture was considered positive. All samples were examined by a professional laboratory expert, without knowledge of the results of clinical examinations. When the whiff and wet test were negative and symptoms of candida were mild, treatment was delayed until preparing the gram staining test and fungal culture and, when all mentioned tests confirmed the candida infection and that was concomitantly negative from Trichomonas and Gardenella, the treatment was begun.

Flow Chart of the Trial Comparing the Effectiveness of a Vaginal Cream Based on Garlic, Zataria multifloraboiss and Clotrimazole in Improving Fungal Vaginitis
Figure 1. Flow Chart of the Trial Comparing the Effectiveness of a Vaginal Cream Based on Garlic, Zataria multifloraboiss and Clotrimazole in Improving Fungal Vaginitis

Garlic and ZMB were purchased from a reliable person and then identified by an expert of the Herb research center, Tabriz University of Medical Sciences, Tabriz, Iran, and were further registered in the herbarium of this center. They were soaked in a solution of ethanol 70% and then stirred for 72 hours in the shaker of the Laboratory of Pharmaceutics, School of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran, under the direction of a pharmacist. The solutions were filtered and the residuum was poured again into ethanol solution and stirred for 72 hours. Then, the extract was removed and added to the first extract and the final extracts were placed on the operator rotary at 40°C, to prepare powders obtained by grinding the particles. The powders were milled and, for preparation of vaginal creams, sodium carboxymethyl cellulose 4% was used. The protected water was prepared using methyl and propyl parabens and appropriate amount of the powders were added to water and stirred until they completely dissolved and dispersed. The sodium carboxymethyl cellulose was added and the mixture was stirred until suitable viscosity vaginal creams 2% were achieved. The prepared vaginal creams were added drops of normal phosphoric acid until, up to a pH = 4. Obtained vaginal creams were placed in the filling machine and poured into sterile tubes, without a name.

Firstly, participants were sampled connivance. Participants with vaginal pruritus, who referred to this center, after confirmatory laboratory test (candidal vaginitis), were selected as sample for research. The participants were divided randomly, into three groups, through a computer random numbers table and block randomization, with block sizes of 3 and 6, with allocation ratio of 1:1:1. They received garlic, ZMB or clotrimazole vaginal cream. The tubes contained 40 grams of garlic (the garlic odor, after preparation of the vaginal cream, was very low or, in several cases, undetectable by human smell), ZMB or clotrimazole vaginal cream that were similar in shape, color and size and were placed in the sealed non-transparent pockets, separately, by a person which was uninvolved in research, according to the allocation sequence, and each participant received one pocket, numbered consecutively. Informed consent was obtained before drug delivery.

Minimum inhibitory concentration (MIC) testing of candidates, for the 40 subjects, according to the Clinical and Laboratory Standards Institute M27-A2 Section 3 [1], was performed. Dilutions of 1%, 2% and 4% of garlic and ZMB extract were prepared. Based on the results of MIC, garlic and ZMB, with a concentration of 2%, were chosen. Due to the ethical consideration of the application of the garlic and ZMB vaginal cream 2% for the first time in this study, for ensuring a minimization of the risk of allergy in the patients, at first, a dental hygiene solution of these extracts was tested, for 2 minutes, and oral examination was performed immediately and 15 minutes after washing. Afterward, the patients were prescribed a vaginal cream.

The patients were advised to apply the creams in a single application (5 gr), every night, for 7 nights, to reach the full depths of the vagina, as well as to avoid intercourse without condom, douching and antibiotic drugs and use hygienic underwear and continue the treatment during menstruation. The participants were asked to complete the checklist of the relief of symptoms and improvement (five levels of improvement). The participants were invited to the clinic 7 days after treatment, to complete the checklist of side effects of garlic, ZMB and clotrimazole. Also, they were examined and the samples of secretion were taken for microscopic inspection and subculture, one week and 4 weeks after completion of treatment, to assess satisfaction and the rate of recovery.

The success of treatment in this study was defined as a negative culture of vaginal discharge and reduction of the severity of symptoms (from grade 2, 3 to grade 1 or zero). In case of absence of curing, treatment was continued with clotrimazole vaginal cream.

3.1. Statistical Analysis

Data were analyzed using v. 21 (SPSS Inc., Chicago, IL, USA). Normality of the quantitative variable for each group was reviewed and upheld through Kolmogorov-Smirnov descriptive test. To describe demography, fertility, personal-social characteristic, clinical and laboratory result, descriptive statistics including mean (standard deviation) and frequency (%) were used. Also, to assess the relationship between demography and fertility, personal-social, clinical and laboratory results, and relief of symptoms and improvement in the intervention group, chi-square, Fisher’s exact test, ANOVA with repeated measure and Kruskal-Wallis tests were used. Significance level was set at P < 0.05.

4. Results

In this trial, 240 women (80 garlic, 80 ZMB and 80 clotrimazole cases) with candidal vaginitis were studied. One week after the procedure, five participants (two of garlic group, one of the ZMB group and two of the clotrimazole group) were excluded, due to lack of willingness to continue treatment and the remaining 235 patients were examined. Participants were followed up clinically and laboratory at one and 4 weeks after the intervention.

Most women were in age group of 34-39 years old, most of them were housewives (80%) and had under diploma education level (60%), while the number of their previous pregnancies was 2-3. Most participants used intrauterine device to prevent pregnancy (40%). Their husbands, job was mostly self-employee. Three groups were similar in socio-demographic and fertility characteristics, such as age, education level, occupation, number of pregnancies and currently used contraception methods (P > 0.05) (Table 1).

Table 1. Comparison of Socio-Demographic and Obstetric Characteristicsa,b
Socio-Demographic and Obstetric CharacteristicsZataria multifloraboiss (n = 80)GarlicClotrimazole (n = 80)P
Age, y
15 - 245 (6.2)5 (6.2)6 (7.5)0.65*
25 - 2913 (16.2)11 (13.8)14 (17.5)
30 - 3418 (22.5)15 (18.8)11 (13.8)
35 - 3926 (32.5)24 (30)26 (32.5)
> 4018 (22.5)25 (31.5)23 (28.8)0.59†
Education level
Primary school10 (12.5)17 (21.2)18 (22.5)
Secondary school10 (12.5)22 (27.5)18 (22.5)0.37§
High school28 (35)34 (42.5)25 (31.2)
University29 (36.2)7 (8.8)22 (27.5)
Occupation
Housewife73 (91.2)73 (91.2)66 (82.5)0.2*
Employee7 (8.8)7 (8.8)14 (.17.5)
Number of pregnancy
No pregnancy4 (5)4 (5)5(6.2)
1 - 363 (82.9)55 (72.4)55(73.3)0.71*
> 413 (17.1)22 (26.7)20(26.7)
Mean (SD)2.4 (1.2)2.8 (1.5)2.6 (1.4)0.45†
Type of delivery
Natural4 (5)30 (37.05)5(6.2)0.63*
Cesarean30 (37.5)46 (57.5)33 (41.2)
Without delivery47 (58.8)4 (5)42 (52.2)
Curettage history11 (13.8)22 (27.5)21 (26.2)0.12 ƒ
The last delivery
< 323 (33.8)16 (21.1)18 (24)0.21 ƒ
> 357 (76)60 (78.9)51 (66.2)
Mean (SD)4.88 (2.8)5.36 (3.5)5.06 (3)0.7†
Current Contraception Methods
OCPs2 (2.5)04 (5)
Condom8 (10)8 (10)5 (6.2)0.45*
IUD36 (45)33 (41.2)34 (42.5)
Withdrawal21 (26.2)21 (26.2)15 (8.18)
TL8 (10)11 (13.8)41 (17.5)
None5 (6.2)6 (7.5)8 (10)

Abbreviations: IUD, Intrauterine Device; OCPs, Oral Contraceptive Pills; TL, Tubal Ligation.

aAll numbers, with the exception of those specified, are displayed as the prevalence (percentage).

bChi-square test*, independent T-square test, Fisher’s exact test ƒ.

Before treatment, the most common clinical complaint in the garlic, ZMB and clotrimazole groups was pruritus, accounting for 96.2%, 100% and 98.7%, respectively. The recovery rates on day 7 after treatment was 84.7%, 84.8% and 85.9% and at 30 days after treatment were 94.9%, 98.7% and 100%, in garlic, ZMB and clotrimazole groups, respectively. There was no significant difference between the three groups at baseline, 7 and 30 days after treatment (P0 = 0.32, P1 = 0.83, P2 = 0.61, respectively). In relation to clinical observations, almost all patients in the garlic, ZMB and clotrimazole groups had vulvovaginal erythema (100%, 97.5% and 98.8%, respectively). The recovery rate on days 7 and 30 after treatment were 82.1%, 70.9%, 84.7% and 97.4%, 96.2%, 96.2%, respectively. No significant difference was observed between groups at baseline, days 7 and 30 after treatment (P0 = 0.77, P1 = 0.13, P2 = 0.74). Other complaints and clinical observation of the patients at three time points between groups showed no significant difference (Table 2). In laboratory examinations, all participants were positive in candida fungi culture and the rate of recovery was reported as 85.9% and 97.4% in garlic, 84.8% and 100% in ZMB group and 89.7% and 100% in clotrimazole group, respectively. There were statistically significant differences in terms of recovery rate, based on culture results, in the three groups between baseline, 7 and 30 days after treatment (P < 0.001). Also, other laboratory parameters showed statistically significant differences between baseline, 7 and 30 days after intervention. The recovery process continued 30 days after treatment in all groups and no recurrence was reported (Table 3).

Table 2. Comparison of the Patient Complaints and Clinical Observations Between Groups at Baseline, 7 and 30 Days After Treatmenta
GroupsGarlicZataria multifloraClotrimazole P0P1P2
Pre-treatment (n = 80)7 Days After Treatment (n = 78)30 Days After Treatment (n = 78)Pre-treatment (n = 80)7 Days After Treatment (n = 79)30 Days After Treatment (n = 79)Pre-treatment (n = 80)7 Days After Treatment (n = 78)30 Days After Treatment (n = 78)
Complaints
Cheesy discharge66 (82.5)1 (1.3)066 (82.5)2 (2.6)062 (77.5)000.670.771
Pruritus77 (96.2)9 (11.5)1 (1.3)80 (100)12 (15.2)1 (1.3)79 (98.7)10 (12.8)00.320.830.61
Urine irritation28 (35)0028 (35)1 (1.3)027 (33.8)0010.371
Irritation in intercourse45 (5.56)0042 (52.5)4 (5.1)1 (1.3)39 (48.8)3 (3.8)00.650.160.37
Pain in intercourse70 (87.5)8 (10.3)073 (91.2)9 (11.6)072 (90)10 (11.8)00.800.901
Clinical observations
Vulvovaginal erythema80 (100)14 (17.9)2 (2.6)78 (97.5)21 (26.6)1 (1.3)79 (98.8)11 (14.1)00.770.130.74
Unnatural cervical appearance72 (90)2 (2.6)2 (2.6)12 (15)2 (2.5)1 (1.3)8 (10)3 (3.8)2 (2.6)0.550.900.84
Inflammation of the vaginal80 (100)16 (20.5)4 (5.1)78 (97.5)22 (27.8)4 (5.1)79 (98.8)16 (20.5)1 (1.3)0.770.481
Unnatural discharge(82.5) 664 (5.1)2 (2.6)62 (77.5)6 (7.6)3 (3.8)62 (77.5)4 (5.1) (5.1)0.690.830.52
Non-homogenous discharge67 (86.2)4 (5.1)2 (2.6)64 (80)5 (6.3)1 (1.3)69 (86.8)1 (1.3)5 (6.4)0.590.350.84
Nontransparent discharge Appearance70 (87.5)5 (6.4)066 (82.5)7 (8.8)070 (87.5)2 (2.6)1 (1.3)0.600.270.55
Discharge color
Grey1 (1.2)4 (5.1)004 (5.1)001 (1.3)041400.62
Cheesy70 (87.5)01 (1.3)65 (81.2)0070 (87.5)1 (1.3)0
Colorless9 (11.2)74 (94.9)77 (100)15 (18.8)75 (94.9)79 (100)10 (12.5)76 (97.4)78 (100)

Abbreviations: P0, Before Intervention; P1 , 7 Days After Intervention; P2, 30 Days After Intervention.

aFisher’s exact test was used for comparison.

Table 3. Comparison of Laboratory Results Between and Within Groups at Baseline, 7 Days and 30 Days After Treatmenta,b
Laboratory ResultsGroupsTime of Study7 Days After Treatment30 Days After TreatmentP *P **P ***
Positive wet mount testZMB76 (95)18 (22.8)1 (1.3)< 0.001< 0.001< 0.001
Clotrimazole80 (100)14 (17.9)0< 0.001< 0.001< 0.001
Garlic79 (98.7)12 (15.4)1.3< 0.001< 0.003< 0.001
P00.18 ƒ0.29*0.60 ƒ
Positive Gram stainZMB54 (67.5)00< 0.001< 0.001< 0.001
Clotrimazole57 (71.2)1 (1.3)0< 0.001< 0.001< 0.001
Garlic62 (77.5)5 (6.4)0< 0.001< 0.001< 0.001
P10.38*0.02 ƒ1 ƒ
Positive culture in agarZMB80 (100)12 (15.2)0< 0.001< 0.001< 0.001
Clotrimazole80 (100)8 (10.3)0< 0.001< 0.001< 0.001
Garlic80 (100)11 (14.1)2 (2.6)< 0.001< 0.004< 0.001
P21 ƒ0.69*0.21 ƒ

Abbreviations: P0, Before Intervention; P1, 7 Days After Intervention; P2, 30 Days After Intervention.; ZMB, Zataria multiflora boiss.

aP *, P **, P ***: Neymar MAC test for the comparison of the group garlic, ZMB and clotrimazole.

bFisher exact test ƒ and chi square test *were used for comparison between groups.

The survey on the relief symptoms and improvement showed that improvement level on the seventh day was in level 5, in more than 79%. However, this was not statistically significant (P = 0.21) (Table 4).

Table 4. Comparison of the Relief of Symptoms and Improvement in the Three Intervention Groups Receiving Vaginal Cream (Garlic, Zataria multiflora boiss and Clotrimazole)
After consumptionStudied groupsA little badNo changeA little goodRelative improvementComplete improvementP valuea
30 minutes after consumptionZMB1 (1.3)11 (13.9)44 (55.7)23 (29.1)00.80
Garlic07 (9)57 (73.1)13 (16.7)1(1.3)
Clotrimazole07 (9)54 (69.2)17 (21.8)0
Second nightZMB1 (1.3)6 (7.6)41 (51.9)31 (39.2)00.20
Garlic07 (9)51 (65.4)20 (25.6)0
Clotrimazole06 (7.7)48 (61.5)23 (29.5)1 (1.3)
Third nightZMB03 (3.8)13 (16.5)61 (77.2)2 (2.5)0.50
Garlic0058 (74.4)19 (24.4)1 (1.3)
Clotrimazole017 (21.8)58 (74.4)3 (3.8)0
Fourth nightZMB008 (10.1)53 (67.1)18 (22.8)0.06
Garlic007 (9)62 (79.5)9 (11,5)
Clotrimazole006 (7.7)56 (71.8)16 (20.5)
Fifth nightZMB002 (2.5)30 (38)47 (59.5)0.25
Garlic0058 (74.4)39 (50)38 (48.7)
Clotrimazole00034 (43.6)44 (56.4)
Sixth nightZMB001 (1.3)16 (20.3)62 (78.5)0.88
Garlic00017 (21.8)61 (78.2)
Clotrimazole00014 (17.9)64 (82.1)
Seventh nightZMB01 (1.3)1 (1.3)13 (16.5)64 (81)0.21
Garlic00016 (20.5)62 (79.5)
Clotrimazole1 (1.3)0013 (16.7)64 (82.1)

Abbreviation: ZMB, Zataria multifloraboiss.

a Kruskal-Wallis test.

Mean (SD) scores of candidiasis symptoms reduced significantly on days 7 and 30, after treatment (P < 0.001) (Table 5).

Table 5. Comparison of the Mean (SD) Scores of Candidal Vaginitis Symptoms at Baseline, days 7 and 30 After Interventiona
Before InterventionAfter Intervention
123P*P**P**
7 Days After Intervention30 Days After Intervention1 × 22 × 3
InterventionGarlic11.23 (2.01)1.79 (1.29)0.01 (-0.11)< 0.001< 0.001< 0.001
ZMB11.23 (1.87)1.07 (1.25)0.03 (-0.25)
ControlClotrimazole11.02 (2.00)1.35 (1.32)0/02 (-0.22)< 0.001< 0.001< 0.001
Adjusted MD (CI 95%)Clotrimazole and garlic0.26 (-1.01 - 0.46)-0.34 (-0.83 - 0.13)0.012 (-0.06 - 0.09)< 0.001< 0.001< 0.001
Pb0.660.090.92
Adjusted MD (CI 95%)cClotrimazole and ZMB0.21 (0.51 - 0.94-)-0.43 (0.51 - 0.09-)0.01 (0.065 - 0.09-)
Pb0.770.210.93
Pd0.66**0.08**0.75**

Abbreviation: MD, Mean Difference; ZMB, Zataria multifloraboiss.

a**, ANOVA with repeated measure (1 × 2) before intervention and 7 days after intervention (2 × 3) 7 days and 30 days after intervention after intervention.

bTukey test for ANOVA.

cAdjusted mean difference.

dOne-way ANOVA for comparing three groups.

Comparison of the Mean (SD) scores of candidal vaginitis symptoms in three groups at baseline, days 7 and 30 after intervention were shown in Figure 2.

The Mean Scores of Candida Vaginitis Symptoms at Baseline, 7 and 30 Days After Intervention
Figure 2. The Mean Scores of Candida Vaginitis Symptoms at Baseline, 7 and 30 Days After Intervention

Although three of the participants in the ZMB group reported irritation on the first day of use and two patients complained of garlic smell and had nausea on the first day, these inconveniences did not prevent the use of drugs.

5. Discussion

The recovery rates in garlic, ZMB and clotrimazole groups, on days 7 and 30 after treatment, based on the results of the agar, were 85.9%, 84.8%, 89.7%, and 97.4%, 100%, 100%, respectively. In this study, the recovery rate of garlic and ZMB was similar to clotrimazole vaginal cream.

Kordi et al. (20) have shown a similar improvement, based on culture for 7 days after treatment, in the garlic and clotrimazole group, with 40.8% and 60.8%, respectively. This is inconsistent with our study. More concentration of active substances in our research (2%) is a possible reason for higher improvement.

Bahadoran et al. (21) have shown that vaginal cream, containing garlic and thyme, is as effective as clotrimazole vaginal cream, for the treatment of candida vaginitis. In the Fouladi research, at 7 days after treatment, recovery percentage (negative laboratory test) in ZMB was 97% and it was 100% with clotrimazole (19). The results of this study are inconsistent to our study, in terms of negative culture at day 7. This difference may result from the difference in the severity of symptoms. However, in our study, the recovery rate, based on the culture at day 30 in the three groups was between 97.4% and 100%. In the Fouladi study, there was no statistically significant difference between the two groups, in terms of recovery based on the culture, compared to the present study (19).

The effect of ZMB vaginal cream 2% in reduction of symptoms of candida was greater compared to the 1% cream used in the Fouladi study (19). In our study, complete improvement of symptoms, in more than 79% of the participants, was reported at day 7. Candida symptoms improvement was similar in all groups. However, in the study of Fouladi et al., improvement was reported at day 7 after treatment in the ZMB group in 54.3% of participants and in the clotrimazole group in 47.4% (19). In our study, recurrence was observed only in two (2.6%) women in garlic group, 30 days after treatment. However, the recurrence rate was not assessed after 30 days by Fouladi et al. and Bahadoran et al. (19, 21). Fardyazar et al. have shown that the recurrence rate in the follow-up period (first 6 months) was 8.6% in fluconazole and 8.5% in clotrimazole group. Recurrence rate in the extended follow-up period (further 6 months) was 38.3% and 40%, respectively (NS) (22).

Kordi et al. reported that complete improvement of symptoms, at day 7 after treatment, in the garlic group, was 51% and in the clotrimazole group was 66.7% (20).

Naeini et al. investigated 50 plant extracts effects on candidosis and showed that thyme and lavender have a very strong antifungal effect (24). Laboratory studies have shown that certain herbs, like ZMB and geranium, also have antimicrobial effect, similar to azole drugs (25).

Jafari et al. indicated that Zataria essence, at concentrations of 50 and 25 mg/mL, removed 100% of attached Candida cells that had adhered to the denture surface, similar to the level of removal observed for 100000 IU nystatine (minimum fungicidal concentration). In this study, 12.5 mg/mL concentration of ZMB was considered as the MIC90 (23).

The comparison of the results of this study with other studies depicts more reduction of complaints after treatment with garlic vaginal cream 2% and ZMB vaginal cream 2%. The most common symptom was pruritus. In the study by Fouladi et al., pruritus was common and 7 days after treatment improvement was reported in 80% of the participants in ZMB group and 71% in the clotrimazole group (19).

In the Fouladi et al. research, the complaints on the cheesy discharge in the ZMB and clotrimazole groups, before treatment, were present in 100% of patients before intervention and at day 7 after treatment the rate was reduced to 40% and 42.1%, respectively (19). Perhaps, the high percentage of the effective substance in the vaginal cream 2%, in comparison with 1%, is more adequate in terms of the patient complaint reduction. There was no follow up at day 30 after treatment in the Fouladi et al. study (19).

There was no difference between the relief of symptoms and improvement level between groups. The majority of the participants in the groups of garlic (79.5 %), ZMB (81%) and clotrimazole (82.1%) had complete recovery on the 7th day and there were no significant differences between the three groups (P = 0.21). In Bahadoran et al. study, the effect of garlic and thyme vaginal cream group was the same as clotrimazole (21). In Fouladi et al. study, the complete recovery was 54.3% in ZMB (1%) group and 47.4% in clotrimazole groups, respectively (19). These studies are inconsistent to our study. Probably, the difference is due to the low number of patients in their study and difference in concentration of drug. Vicariotto et al. showed that natural substances are more relieving than chemical substances in candidiasis symptoms (26).

One of the strong points of this study is the application of garlic and ZMB 2% in the treatment of candidal vaginitis, higher sample size and, also, follow-up for 30 days after treatment for recurrence.

However, this study had several limitations. We did not had enough time for long time follow up of patients and possible loss of participants, and, also, the severity of the symptoms was reported based on clinical examination. Virgins were excluded from this study. According to several researchers, there is likelihood of transmission of the microbes from the intestine to vagina, especially in cases of recurrent candidal vaginitis and it is particularly recommended to further study intestinal microorganisms (27).

Garlic and ZMB vaginal cream 2% is effective in the treatment of candidal vaginitis, prevention of recurrence after 30 days and improvement of clinical symptoms and signs. Consequently, it can be an effective treatment option in cases of drug resistance and in cases where subjects prefer treatment with herbal medicines.

Acknowledgements

Footnotes

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