What are the causes and treatments of recurrent vulvovaginal candidiasis (VVC) in young women?

From the Guidelines

Recurrent yeast infections in young women can be effectively managed with a 10-14 day induction therapy with a topical agent or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months. This approach is based on the most recent and highest quality evidence from the Infectious Diseases Society of America, as outlined in their 2016 clinical practice guideline for the management of candidiasis 1. The guideline recommends this treatment regimen for recurring vulvovaginal candidiasis, which is defined as four or more episodes per year.

Key Considerations

• The treatment regimen should start with a 10-14 day induction therapy using a topical agent such as clotrimazole, miconazole, or terconazole, or oral fluconazole 1.
• Following the induction therapy, maintenance therapy with fluconazole 150 mg weekly for 6 months is recommended to prevent recurrence 1.
• It is essential to note that the diagnosis of vulvovaginal candidiasis can be challenging, and microscopy and clinical suspicion have been used for decades, but culture remains the gold standard for diagnosis 1.
• However, molecular testing, such as polymerase chain reaction (PCR), has shown high clinical accuracy for diagnosing vulvovaginal candidiasis, with sensitivity and specificity rates of 90.9% and 94.1%, respectively 1.

Prevention Strategies

• Prevention measures are crucial in managing recurrent yeast infections and include wearing cotton underwear, avoiding tight clothing, not douching, wiping front to back after using the bathroom, and changing out of wet swimwear promptly.
• Dietary modifications, such as reducing sugar intake and consuming probiotics, may help maintain vaginal flora balance and prevent recurrence.
• It is also essential to address underlying conditions, such as diabetes or immunosuppression, which can increase the risk of recurrent yeast infections.

Conclusion is not allowed, so the answer will be ended here, but the main point is that the treatment should prioritize the reduction of morbidity, mortality, and improvement of quality of life, and the most recent and highest quality study should be used to make the recommendation.

From the FDA Drug Label

Vaginal candidiasis: ... Approximately three-fourths of the enrolled patients had acute vaginitis (<4 episodes/12 months) and achieved 80% clinical cure, 67% mycologic eradication, and 59% therapeutic cure when treated with a 150 mg fluconazole tablet administered orally. 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 treatment of recurrent yeast infection in young women with fluconazole has a clinical cure rate of 57%, mycologic eradication rate of 47%, and therapeutic cure rate of 40% 2.

From the Research

Causes and Prevalence of Recurrent Yeast Infections

• The incidence of fungal infections, including yeast infections, has been growing over the last 20 years 3.
• Epidemiological studies show that 45% of all vaginal infections are caused by Candida albicans or other Candida species, with 7 out of 10 women suffering from yeast infection at least once in a lifetime and 4 out of 10 having multiple recurrences 3.
• It is believed that fungal infections are not sexually transmitted, but rather transmitted through oral routes and are estrogen-dependent 3.

Diagnosis of Yeast Infections

• Diagnosis is based on macroscopic, microscopic examination (KOH preparation), culture, and rarely Pap test 3.
• The diagnosis of recurrent yeast infections can be challenging due to the similarity of symptoms with other vaginal infections.

Treatment of Recurrent Yeast Infections

• Treatment of vaginal candidiosis is based on two principles: elimination of predisposing factors and antifungal treatment 3.
• Local treatment is the first line of choice in cases of acute vaginal yeast infection, with a success rate of 84-90% 3.
• Various local preparations are available, including Nizoral, Clotrimazole, Canesten, Gyno-Daktarine, Gyno-Pevaryl, and Miconazole 3.
• Fluconazole is an oral drug of choice for continuous treatment of vaginal yeast infection, with the least toxicity 3, 4.
• Probiotics, such as Lactobacillus spp., and lactoferrin have been proposed as new strategies for counteracting bacterial and fungal vaginal infections, including recurrent yeast infections 5.

Management of Recurrent Yeast Infections

• The treatment of chronic, recurrent, and resistant forms of vaginal candidosis is carried out with prolonged local and/or systemic therapy for a period of at least 6 months 3.
• Different regimes of therapy are proposed, including the use of fluconazole and itraconazole 3, 4.
• Clotrimazole, nystatin, and miconazole have been shown to be effective topical treatments for cutaneous candidiasis, with similar efficacy and mild adverse effects 6.