Chronic and recurrent vulvovaginal candidiasis

Approximately 15 % of non-pregnant women and 30 % of pregnant women yield positive cultures of Candida species in the vaginal specimens. A diagnosis of vulvovaginal candidiasis (VVC) should only be made when Candida spp. are isolated from the vulvovaginal area, together with the presence of signs and symptoms. In Japan several topical drugs for vaginal candidiasis are available, but oral azoles has not been approved. According to our studies, treatment with topical drugs resulted in symptomatic cure and negative culture conversion in 80 %-90 % of patients at the end of initial treatment (6-14 days or high-dose one day treatment according to the drug used). However Candida spp. reappeared in the vagina after several weeks in 7-34 % (according to the drug used) of initially cured cases, and some of them were again symptomatic. A small proportion of women experienced three or more episodes of symptomatic VVC annually. Repeated reinfection from a gastrointestinal reservoir or sexual transmission, subclinical presence of yeasts in the vagina, impaired host defense mechanisms, enhanced Candida virulence have been discussed as factors relating to recurrent vulvovaginal candidiasis (RVVC). Oral ketoconazole give the best result in treating RVVC, however it is not used because of possible side effects. Several studies have evaluated oral therapy for RVVC with fluconazole and itraconazole that have less side effects. However, several reports have documented the emergence of fluconazole-resistant candidiasis in long-term treatment of mycotic diseases other than VVC. The optimal treatment for RVVC remains difficult to establish.