What is the workup for recurrent vulvovaginal candidiasis (VVC)?

From the Guidelines

For recurrent yeast vaginitis workup, first confirm the diagnosis with microscopy and culture to identify the specific Candida species, as non-albicans species may require different treatment approaches, and consider using molecular testing such as polymerase chain reaction (PCR) for diagnosis due to its high clinical accuracy 1.

Diagnosis and Treatment

• Initial management includes a longer course of antifungal therapy, such as fluconazole 150 mg orally every 72 hours for three doses, followed by weekly fluconazole 150 mg for 6 months as maintenance therapy, as recommended by the Infectious Diseases Society of America 1.
• For non-albicans species or fluconazole resistance, consider boric acid 600 mg vaginal suppositories daily for 14 days.
• Address modifiable risk factors by recommending loose cotton underwear, avoiding douching and scented products, managing blood glucose in diabetic patients, and considering discontinuation of unnecessary antibiotics.

Evaluation and Referral

• Evaluate for underlying conditions such as uncontrolled diabetes, immunosuppression, or HIV.
• For patients with four or more episodes per year despite these measures, consider referral to a specialist for further evaluation.
• Recurrent yeast infections often result from incomplete eradication of the original infection, allowing regrowth from residual organisms, or from persistent risk factors that promote Candida overgrowth in the vaginal environment.

Molecular Testing

• Molecular testing such as PCR has been shown to have high sensitivity and specificity for diagnosing vulvovaginal candidiasis, and can be used to confirm the diagnosis and identify the specific Candida species 1.
• The use of molecular testing can help reduce the risk of misdiagnosis and unnecessary treatment, and can guide treatment decisions for patients with recurrent yeast vaginitis.

From the FDA Drug Label

Vaginal candidiasis: ... The remaining one-fourth of enrolled patients had recurrent vaginitis (≥4 episodes/12 months) and achieved 57% clinical cure, 47% mycologic eradication, and 40% therapeutic cure

The workup for recurrent yeast vaginitis is not directly addressed in the FDA drug label. However, the label does provide information on the treatment of vaginal candidiasis, including recurrent cases.

• Clinical cure was achieved in 57% of patients with recurrent vaginitis.
• Mycologic eradication was achieved in 47% of patients with recurrent vaginitis.
• Therapeutic cure was achieved in 40% of patients with recurrent vaginitis. 2

From the Research

Recurrent Yeast Vaginitis Workup

Recurrent yeast vaginitis, also known as recurrent vulvovaginal candidiasis (RVVC), is a common condition that can be challenging to manage. The workup for this condition involves several steps, including:

• Diagnosis: The diagnosis of RVVC is typically made based on clinical symptoms, such as vaginal itching, burning, and discharge, as well as a positive culture for Candida species 3, 4.
• Treatment: The treatment for RVVC typically involves antifungal medications, such as fluconazole, which can be given orally or intravaginally 3, 4, 5.
• Maintenance therapy: Maintenance therapy with antifungal medications, such as fluconazole, may be necessary to prevent recurrence 3, 6.
• Alternative therapies: Alternative therapies, such as boric acid, may be effective for women with recurrent and chronic symptoms of vaginitis when conventional treatment fails 7.

Treatment Options

The treatment options for RVVC include:

• Fluconazole: Fluconazole is an effective treatment for RVVC, with a mycological cure rate of 73.2% at 9 months 3.
• Nystatin: Nystatin is also an effective treatment for RVVC, with a mycological cure rate of 78.3% after initial therapy 5.
• Boric acid: Boric acid is a safe and effective alternative therapy for women with recurrent and chronic symptoms of vaginitis when conventional treatment fails 7.
• Combined therapy: Combined therapy with systemic and topical antifungal medications, such as fluconazole and metronidazole + clotrimazole, may be effective in reducing the rate of recurrence of RVVC 6.

Considerations

When managing RVVC, several considerations should be taken into account, including:

• Resistance: Resistance to antifungal medications, such as fluconazole, is a concern in the treatment of RVVC 5.
• Non-albicans Candida: Non-albicans Candida species, such as C. glabrata, may be more resistant to conventional antifungal treatment and require alternative therapies 7, 5.
• Biofilm formation: Biofilm formation by Candida species may contribute to the recurrence of RVVC and require specific treatment strategies 6.