The Basics - Recurrent vaginal candidiasis

Recurrent vulvovaginal candidiasis is defined as four or more episodes in a year. By Dr Louise Newson.

Vaginal thrush: endoscope view showing C albicans (Photograph: SPL)
Vaginal thrush: endoscope view showing C albicans (Photograph: SPL)

Vulvovaginal candidiasis (VVC or thrush) is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection - commonly Candida albicans.

Recurrent vulvovaginal candidiasis (RVVC) is defined as four or more episodes in a year, with at least partial resolution of symptoms between episodes.

Approximately 5 per cent of women of reproductive age with a primary episode of VVC will develop recurrent disease.

1. Aetiology
RVVC is usually due to infection with C albicans. Predisposing factors include diabetes mellitus, immunosuppression and disturbance of vaginal flora (with broad-spectrum antibiotics). A link to allergy has also been demonstrated.

There is no evidence that iron deficiency is implicated in the pathogenesis of RVVC. One study reported a statistically significantly lower serum level of zinc, magnesium and calcium in patients with RVVC;1 however other studies have not demonstrated this association.

2. Investigations
Women should have vaginal swabs taken to confirm the clinical diagnosis and also to identify unusual species. The British Association for Sexual Health and HIV guidelines state that positive microscopy or a moderate or heavy growth of C albicans should be documented on at least two occasions.

C glabrata does not form pseudohyphae or hyphae and is not easily recognised on microscopy. C glabrata and other candida species are seen in around 10-20 per cent of patients with RVVC. Any reversible causes of RVVC need to be eliminated. However, in most women with RVVC, no underlying or predisposing factor is identified.

3. Management
Treatment of RVVC aims to control rather than cure the infection. The following measures may be useful:

  • Avoid using bubble baths and spermicides, as these may alter the normal vaginal flora.
  • Avoid nylon underwear or tight-fitting jeans.
  • Women prone to thrush after taking antibiotics may find it useful to have antifungal treatment prescribed.
  • Friction during intercourse may cause minor damage to the vagina wall, which may make candida more likely to thrive. Some women may be advised to use a lubricant.

Although each individual episode of RVVC caused by C albicans responds well to short duration oral or topical azole therapy, many patients find their symptoms return.

Therefore, a longer duration of initial treatment (seven to 14 days of topical therapy or oral fluconazole every third day for a total of three doses) may be preferable.

Oral fluconazole weekly for six months is usually the first line of maintenance treatment. This should be avoided in pregnancy or when breastfeeding. Alternative maintenance treatment would be topical clotrimazole twice a week, clotrimazole 500mg dose vaginal suppositories once weekly or other topical treatments.

Some women find that their VVC recurs monthly. It can be beneficial for these women to be prescribed cyclical antifungal treatment (fluconazole orally on day 21 of each cycle or a clotrimazole vaginal pessary on days seven and 21).

Treatment with zafirlukast for six months may induce remission and it is sometimes even considered as maintenance prophylaxis for those women with RVVC and a history of atopy.2 Maintenance treatment with cetirizine may cause remission in women who fail to get resolution of symptoms with suppressive fluconazole.2

There is little scientific evidence to show that natural remedies are effective. The use of lactobacillus probiotics has been shown not to be effective.3

In addition, a recent trial shows monthly itraconazole is more effective than classical homeopathy in treating RVVC.4

4. Prognosis
Around 90 per cent of women will remain disease free at six months and 40 per cent at one year.

However, if infection occurs during a maintenance period, they should be referred for specialist treatment, as the infection may be due to azole resistance by a non-albicans infection. In these cases, nystatin, boric acid or flucytosine may be used.

  • Dr Newson is a GP in the West Midlands

References
1. Spacek J, Jilek P, Buchta V et al. Mycoses 2005; 48(6): 391-5.

2. Neves NA CLLACACE. J Low Genit Tract Dis 2005; 9(3): 167-70.

3. Abad CL, Safdar N. J Chemother 2009; 21: 243-52.

4. Witt A, Kaufmann U, Bitschnau M et al. Br J Obstet Gynaecol 2009; 116: 1499-505.

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