Complicated Vulvovaginal Candidiasis (VVC)

Recurrent Vulvovaginal Candidiasis

Recurrent vulvovaginal candidiasis (RVVC), usually defined as four or more episodes of symptomatic VVC each year, affects a small percentage of women (<5%). The pathogenesis of RVVC is poorly understood, and most women who have RVVC have no apparent predisposing or underlying conditions. Vaginal cultures should be obtained from patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including non-albicans species, particularly Candida glabrata ( C. glabrata does not form pseudohyphae or hyphae and is not easily recognized on microscopy). C. glabrata and other non-albicans Candidia species are found in 10%--20% of patients with RVVC. Conventional antimycotic therapies are not as effective against these species as against C. albicans .

Treatment

Each individual episode of RVVC caused by C. albicans responds well to short duration oral or topical azole therapy. However, to maintain clinical and mycologic control, specialists recommend a longer duration of initial therapy (e.g., 7--14 days of topical therapy or a 150-mg, oral dose of fluconazole repeated 3 days later) to achieve mycologic remission before initiating a maintenance antifungal regimen.

Maintenance Regimens

Maintenance antifungals are selected on the basis of pharmacologic characteristics of individual agents and route of administration. Recommended regimens include clotrimazole (500-mg dose vaginal suppositories once weekly), ketoconazole (100-mg dose once daily), fluconazole (100--150-mg dose once weekly), and itraconazole (400-mg dose once monthly or 100-mg dose once daily). Although all maintenance regimens should be continued for 6 months, an estimated one in 10,000--15,000 persons exposed to ketoconazole may develop hepatotoxicity. Patients receiving long-term ketoconazole should be monitored for toxicity.

Suppressive maintenance antifungal therapies are effective in reducing RVVC. However, 30%--40% of women will have recurrent disease once maintenance therapy is discontinued. Routine treatment of sex partners is controversial. Although C. albicans azole resistance is rare in vaginal isolates, surveillance of recurrent isolates for development of resistance is prudent.

Severe VVC

Severe vulvovaginitis (i.e., extensive vulvar erythema, edema, excoriation, and fissure formation) has lower clinical response rates in patients treated with short courses of topical or oral therapy. Either 7--14 days of topical azole or 150 mg of fluconazole in two sequential doses (second dose 72 hours after initial dose) is recommended.

Non-albicans VVC

The optimal treatment of non- albicans VVC remains unknown. Longer duration of therapy (7--14 days) with a non-fluconazole azole drug is recommended as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks. This regimen has clinical and mycologic eradication rates of approximately 70%. Additional options include topical 4% flucytosine; however, referral to a specialist is advised. Safety data regarding the long-term use of these regimens are lacking. If non- albicans VVC continues to recur, a maintenance regimen of 100,000 units of nystatin delivered daily via vaginal suppositories has been successful.

Compromised Host

Women with underlying debilitating medical conditions (e.g., those with uncontrolled diabetes or those receiving corticosteroid treatment) do not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7--14 days) conventional antimycotic treatment is necessary.

Pregnancy

VVC often occurs during pregnancy. Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women.

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National Guideline Clearinghouse