Recurrent vulvovaginal candidiasis

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Abstract

Recurrent vulvovaginal candidiasis is a prevalent opportunistic mucosal infection, caused predominantly by Candida albicans. This condition affects a significant number of otherwise healthy women of childbearing age, and it causes significant discomfort. Patients who have chronic vulvovaginitis should be thoroughly evaluated to determine the specific etiology and to initiate appropriate therapy. Induction therapy, followed by a maintenance regimen, seems to reduce relapse. Alternative therapies should be considered for recalcitrant cases.

Introduction

Vaginitis is a common gynecologic disorder that is responsible for 10 million office visits to physicians each year (1). Candida albicans is the second most common cause of vaginal infections; bacterial vaginosis is the most common (2). C. albicans may be isolated from the genital tracts of approximately 20% (range, 10 to 55%) of asymptomatic healthy women in their childbearing years (3). The hormonal dependency of this condition on estrogens is also evident by the rarity of Candida isolation in pre-menarchal girls and the lower prevalence of candidal vaginitis in postmenopausal women.

Recurrent vulvovaginal candidiasis is a prevalent opportunistic mucosal infection, caused predominantly by C. albicans (3). This condition affects a significant number of otherwise healthy women of childbearing age, and it can cause significant discomfort and concern. Misdiagnosis of vaginitis is common (4). It is therefore critical that patients who have chronic vaginitis be thoroughly evaluated to determine if there is a specific etiology and whether their condition is recurrent, persistent, or a re-infection (5).

Section snippets

Types of infection

The most common yeasts isolated from the vagina are C. albicans (85 to 90%), followed by Candida glabrata (5 to 10%) and Candida tropicalis (1 to 3%). Other less common species are Candida stellatoidea, Candida krusei, Candida famata, and Saccharomyces cerevisiae (0.5 to 2%) (6). More than 200 strains of C. albicans have been identified. All strains appear capable of colonization and can cause vaginitis; uniquely virulent strains have not been identified (7). Of women who have positive cultures

Pathogenesis

Despite recent advances in microbiology, we still have limited understanding of the pathogenesis of this common fungal infection. We do know that to develop an infection in the vagina, alterations are necessary in the vaginal epithelium, the microbial flora, or the microbe implicated. Recent studies have suggested that instead of vulvovaginal candidiasis being caused by defective or dysfunctional CD4 T helper 1-type cell-mediated immune reactivity, symptomatic candidiasis is associated with an

Recurrent and chronic vulvar candidiasis

Five factors have been shown to contribute to the acquisition and/or induction of a symptomatic recurrence or chronicity of vulvar candidiasis.

Diagnosis

Candidiasis typically presents as a thick and curdled white discharge with vulvar pruritus, a hyperemic vagina, and an erythematous and/or excoriated vulva. The vaginal pH is usually in the normal range of 3.8 to 4.2 in uncomplicated candidiasis (8). Microscopic examination of the discharge reveals hyphae or budding yeast in 50 to 70% of the cases.

The lack of specific signs and symptoms precludes a diagnosis based on history or physical examination alone. Self-diagnosed vulvovaginal candidiasis

Therapy

Most regimens in current use for recurrent or chronic fungal vulvovaginal infections are empirical and not evidence based (20). A recent study by Sobel et al. (21) concluded that long- term weekly treatment with fluconazole could reduce the rate of recurrence of symptomatic vulvovaginal candidiasis.

Principles of therapy include induction therapy, followed by a maintenance therapy for 6 months (3). Therapy interruption may result in relapse in about 50% of patients. Alternative therapies should

Conclusions

Effective treatment of recurrent vulvovaginal candidiasis requires accurate diagnosis based on a detailed history and physical examination, bacterial and fungal specimens for culture, and appropriate therapy based on an induction and a maintenance regimen.

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