What evaluation and treatment should be considered for a patient presenting with chronic vulvovaginal candidiasis?

From the Guidelines

For a patient presenting with chronic yeast infections, a thorough evaluation and treatment approach should prioritize identifying the Candida species, addressing modifiable risk factors, and implementing a comprehensive management plan to reduce recurrence risk and improve quality of life. When evaluating a patient with chronic vulvovaginal candidiasis (CVVC), it is essential to consider the following key points:

• A thorough history and physical examination to identify potential underlying conditions that may be contributing to the recurrent infections, such as diabetes, HIV, or immunosuppression 1.
• Microscopic confirmation with KOH preparation or fungal culture to identify the Candida species, as non-albicans species may require different treatment approaches 1.
• Initial treatment involves a longer course of antifungal therapy, typically fluconazole 150 mg orally every 72 hours for 3 doses, followed by weekly maintenance therapy for 6 months, as recommended by the 2016 update by the Infectious Diseases Society of America 1.
• For fluconazole-resistant cases, options include topical treatments such as clotrimazole 1% cream applied daily for 7-14 days or boric acid 600 mg vaginal suppositories daily for 14 days, as outlined in the 2021 Centers for Disease Control and Prevention treatment guidelines 1.
• Patients should be counseled on modifiable risk factors, including:
  • Avoiding tight-fitting clothing
  • Using non-perfumed hygiene products
  • Managing blood glucose if diabetic
  • Considering discontinuation of spermicides or hormone therapy if possible
• Recurrent infections may warrant suppressive therapy and investigation of underlying conditions, with a focus on improving quality of life and reducing morbidity and mortality 1. The most recent and highest quality study, published in 2022, provides guidance on the diagnosis and treatment of vulvovaginal candidiasis, including the use of molecular testing and the recommended regimens for treatment 1.

From the Research

Evaluation of Chronic Vulvovaginal Candidiasis

To evaluate a patient presenting with chronic vulvovaginal candidiasis, the following information should be considered:

• Medical history, including previous treatments for vulvovaginal candidiasis and any underlying medical conditions that may be contributing to the chronic nature of the infection 2, 3
• Symptoms, including duration, severity, and any factors that exacerbate or relieve them
• Physical examination findings, including signs of vulvovaginal inflammation or discharge
• Laboratory test results, including fungal culture and sensitivity testing to identify the causative species of Candida and its susceptibility to antifungal agents 4, 5

Treatment Considerations

Treatment of chronic vulvovaginal candidiasis should be individualized based on the patient's specific needs and circumstances:

• Antifungal agents, such as fluconazole, itraconazole, clotrimazole, and miconazole, may be effective in treating the infection, but the choice of agent and treatment regimen should be guided by the results of fungal culture and sensitivity testing 2, 4, 6
• Topical antifungal agents, such as clotrimazole and miconazole, may be preferred for their ease of use and minimal side effects, but oral agents, such as fluconazole and itraconazole, may be necessary for more severe or recurrent infections 5, 6
• Treatment duration and frequency should be tailored to the patient's response to therapy and the severity of the infection
• Consideration should be given to the patient's pregnancy status, as some antifungal agents may be contraindicated or require dose adjustment during pregnancy 5

Additional Considerations

Additional factors that may contribute to the development of chronic vulvovaginal candidiasis should be considered, including:

• Underlying medical conditions, such as diabetes or immunosuppression, that may increase the risk of developing fungal infections 2, 3
• Use of antibiotics or other medications that may disrupt the normal vaginal flora and contribute to the development of fungal infections
• Dietary and lifestyle factors, such as dietary sugar intake and hygiene practices, that may contribute to the development of fungal infections 5