Recurrent VVC — What works?

The next file in your inbox is for a 35-year-old woman who has had recurrent vaginal infections. In the past year, she has had numerous episodes of itching, burning, and abnormal discharge. When you walk into the exam room, she presents you with a large bag filled with an assortment of antifungal and antibiotic preparations. What can you do to help break the cycle of recurrent infection?

Obtaining an appropriate history is the first step in moving toward an accurate diagnosis and treatment plan, says Paul Nyirjesy, MD, professor of obstetrics and gynecology at and director of the Drexel Vaginitis Center at Drexel University College of Medicine in Philadelphia.

Take nothing for granted, especially when patients say they have yeast infections, says Nyirjesy, who presented on persistent vaginal infections at the recent Contraceptive Technology Quest for Excellence conference.1

"Your job is to get as accurate a diagnosis as possible," notes Nyirjesy. "Start with a symptom-specific history."

VVC — What is it?

Vulvovaginal candidiasis (VVC) usually is caused by Candida albicans, but its mycology also includes Candida glabrata, Candida parapsilosis, Candida krusei, Candida lusitaniae, Candida tropicalis, and Saccharomyces cerevisiae. Typical symptoms include pruritus, vaginal soreness, dyspareunia, external dysuria, and abnormal vaginal discharge.2 About 20% of patients in the Drexel University program present with VVC, says Nyirjesy.

Vulvar diseases are frequently misdiagnosed as VVC, and in turn, VVC frequently complicates many vulvar problems, says Nyirjesy. Accurate diagnosis with culture corroboration is crucial for women with recurrent infections, he states.

"Most women who come in to see me tell me they have recurrent yeast infections; by the time they get to me, only 25% do," he states. "Of the 25% who do, about a third are due to yeast other than Candida albicans, and then the treatment approach may be very different."

In determining recurrent VVC, look for vaginal/vulvar erythema and/or edema, an adherent white discharge, normal pH, and hyphae or blastospores on wet mount or potassium hydroxide (KOH) prep, Nyirjesy notes. Fungal cultures corroborate microscopic findings, are more sensitive than the microscope to detect the presence of yeast, and allow for speciation. Yeast polymerase chain reaction testing offers no proven clinical equivalence or benefit over culture; it is more costly, and it might miss certain species, says Nyirjesy.

What's your approach?

For women who have routine uncomplicated episodes of vulvovaginal candidiasis, a variety of effective treatment options exists. Recurrent disease remains a challenge, but it often can be managed successfully.3

Recurrent vulvovaginal candidiasis is usually defined as four or more episodes of symptoms. Maintenance fluconazole might be helpful: in a double-blind study, weekly treatment with fluconazole was effective in preventing symptomatic vulvovaginal candidiasis. The proportions of women who remained disease-free at six, nine, and 12 months in the fluconazole group were 90.8%, 73.2%, and 42.9%, as compared with 35.9%, 27.8%, and 21.9%, respectively, in the placebo group.4

The Centers for Disease Control and Prevention's Sexually Transmitted Diseases Treatment Guidelines states that oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for six months is the first line of treatment as a maintenance regimen for recurrent VVC. If this regimen is not feasible, you can consider topical treatments used intermittently as a maintenance regimen, the guidance notes.2

What if the problem is due to non-albicans Candida infection? The optimal treatment of non-albicans VVC remains unknown, says the CDC. Options include longer duration of therapy (7-14 days) with a nonfluconazole azole drug (oral or topical) as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for two weeks.2 This regimen has clinical and mycologic eradication rates of approximately 70%.5

Make sure it's yeast

Never take it on faith that it's a yeast infection. It often isn't, says Nyirjesy.

"In symptomatic women, culture for yeast and culture often," he suggests.

"If yeast is there, you won't know it's causing symptoms until you get rid of it."

If cultures point to Candida albicans, consider maintenance fluconazole, Nyirjesy suggests. If it is some other yeast species and an azole treatment doesn't work, try boric acid first, he says.

References

  1. Nyirjesy P. The perplexing problem of persistent vaginitis. Presented at the Contraceptive Technology Quest for Excellence conference. Atlanta; November 2011.
  2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12):61-63.
  3. Nyirjesy P. Vulvovaginal candidiasis and bacterial vaginosis. Infect Dis Clin North Am 2008; 22:637-52, vi.
  4. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. NEJM 2004; 351:876-883.
  5. Sobel JD, Chaim W, Nagappan V, et al. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol 2003; 189:1,297-1,300.