A recurrence may also represent an inadequately treated infection. For example, a patient may not complete the entire course of antifungal therapy, especially if an inconvenient topical treatment has been prescribed. 5, 7 – 15 Noncompliance with a treatment regimen may result in persistent infection that is mislabeled as a recurrence. 6Īlthough antifungal resistance can cause treatment failure, other factors may contribute to recurrent vulvovaginal candidiasis ( Table 1). albicans and found that no strain was resistant to ketoconazole, itraconazole and clotrimazole. A 1993 in vitro study examined more than 250 strains of C.

5 Imidazoles are still the first-line treatment for C. glabrata are 10 times less sensitive to miconazole than is C. In vitro studies have shown that imidazole antifungal agents such as miconazole and clotrimazole are not as effective against non– C. 4 In fact, recurrent infections may be caused by the resistance of non– C. albicans have been found to cause yeast vaginitis (i.e., 9.9 percent of cases in 1988 and 17.2 percent of cases in 1995).

Increasingly, Candida species other than C. In addition, a wet mount should be examined for evidence of coexisting trichomoniasis or bacterial vaginosis.Īlthough Candida albicans is the pathogen identified in most patients with vulvovaginal candidiasis, other possible pathogens include Candida tropicalis and Candida glabrata. 3 Fungal cultures should be obtained when clinical suspicion is high and the KOH preparation is negative, or when a patient has persistent or recurrent symptoms despite treatment. Characteristic budding mycelia are seen in fewer than 30 percent of positive candidal cultures. Microscopic examination of vaginal secretions in a 10 percent KOH preparation may demonstrate hyphae. Potassium hydroxide (KOH) testing and fungal cultures have some limitations, but they are still useful for identifying the infecting species and guiding treatment. On physical examination, the patient with vulvovaginal candidiasis usually has vulvar erythema and a thick, white to yellow discharge in the vaginal vault. Patients who self-diagnose yeast infections risk missing other etiologies or concurrent infections involving two or more organisms that require different treatments. Frequently, these women express their frustration with ineffective treatments.Īlthough the initial infection is sometimes diagnosed over the telephone, clinical evaluation of recurrent episodes is essential. Other presenting symptoms may include an odorless vaginal discharge, pruritus, dyspareunia or dysuria. Women who have persistent or recurrent vulvovaginal candidiasis often present to their family physician with intense vaginal discomfort. Recurrent vulvovaginal candidiasis is distinguished from persistent infection by the presence of a symptom-free interval.

2 Vulvovaginal candidiasis is considered recurrent when at least four discrete episodes occur in one year or at least three episodes occur in one year and are not related to antibiotic therapy. More than 50 percent of women older than 25 years have one episode of vulvovaginal candidiasis, 1 but fewer than 5 percent of these women experience recurrent infection. Patients are more likely to comply when antifungal therapy is administered orally, but oral treatment carries a greater potential for systemic toxicity and drug interactions. Because many patients experience recurrences once prophylaxis is discontinued, long-term therapy may be warranted. After the acute episode has been treated, subsequent prophylaxis (maintenance therapy) is important. If microscopic examination of vaginal secretions in a potassium hydroxide preparation is negative but clinical suspicion is high, fungal cultures should be obtained. Known etiologies of recurrent vulvovaginal candidiasis include treatment-resistant Candida species other than Candida albicans, frequent antibiotic therapy, contraceptive use, compromise of the immune system, sexual activity and hyperglycemia. Patients who self-diagnose may miss other causes or concurrent infections. Clinical evaluation of recurrent episodes is essential. Although greater than 50 percent of women more than 25 years of age develop vulvovaginal candidiasis at some time, fewer than 5 percent of these women experience recurrences. Vulvovaginal candidiasis is considered recurrent when at least four specific episodes occur in one year or at least three episodes unrelated to antibiotic therapy occur within one year.

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