Vuvlvovaginal-Candidiasis-(

Candida Albicans (candidiasis)

Vulvovaginal candidiasis (VVC) affects 70% to 75% of women at least once in their life over the reproductive period [SOBEL 1988]; some 40% to 50% will have a 2nd episode. The incidence of recurrent VVC (RVVC) (defined by the occurrence of at least four episodes per year, two of them proven by culture [SOBEL 1998, SHEARY 2005]) has been estimated at between 5% and 8% [SOBEL 2003, SOBEL 2004, FOXMAN 2000]. This benign infection has a very negative effect on patients’ quality of life [FOXMAN 2000] and incurs significant healthcare costs.

It is a mucocutaneaous infection caused by Candida albicans in 85 to 90% cases, and the 10 to 15% left are caused by other Candida species (C. glabrata and C. tropicalis mainly) [FIDEL 1996].

Antibiotic therapy, usage of spermicides, oestrogen therapy, diabetes mellitus, wearing tight clothes and having frequent sexual relationships are risk factors for VVC [JEAVONS 2003].

The diagnosis of VVC is not clear on a clinical plan as the functional signs are non-specific (pruritus, vaginal discharge, erythema and oedema vulvar, vaginal burns).

Differential diagnosis eliminates vulvar dermatitis (psoriasis, lichen, etc.), genital herpes, bacterial vaginosis, and urinary tract infection. The diagnosis must be confirmed by mycological examination (direct microscopy and/or culture).

Studies upon the quality of life for women having RVVC showed:

  • 33% feel sick constantly even if recurrences are spaced
  • 79% reported a negative impact on their sex life (fear of triggering a crisis, fear of pain, fear of contaminating partner, etc.)
  • 75% reported difficulty participating in social or professional life

This benign condition also affects the “self-image”:

  • 24% are ashamed of the disease
  • 36% are worried about the consequences of the infection
  • 71% are frustrated

The lack of information on the genesis of these recurrences and poor results for long-term prescribed treatment participate in the very negative impact of this infection [LACHOWSKY 2007].

Treatment

C_tropicalis_YC466 (candidiasis)

RVVC may be difficult to treat because of the many factors involved in its origin and development. Traditional maintenance treatment by oral or vaginal antifungals should continue for at least six months, but the recurrence rate remains high, with 60% to 70% of women suffering a recurrence within two months of ceasing treatment [SOBEL 2003, WATSON 2007, DONDERS 2008, SOBEL 2006]. Moreover, antifungals have frequent side effects and long-term use can lead to bacterial vaginosis (BV).

Systematic reviews strongly supporting a particular treatment over another under conventional care of RVVC are missing from the literature. Recommendations are mainly established on the basis of the few randomized controlled trials and expert opinions [WATSON 2007].

The treatment of an acute episode (local or mixed) followed by a long-term maintenance treatment with an azole antifungal is today the standard care for most patients. Despite few comparative studies, the best results were obtained with a long-term treatment, using a weekly dose of 150 mg of fluconazole. However, fluconazole is a suppressive treatment as such, inhibiting growth but not guaranteeing the eradication of the yeast involved. Upon discontinuation of fluconazole, after six months of weekly administration, it is expected that 60 to 70% of patients quickly relapse with a symptomatic episode of VVC. Most of the time, the relapse occurs within two months after stopping fluconazole [SOBEL 2003]. In most cases, relapse is due to the same strain responsible for the initial episode of VVC. Another background therapy should then be offered to the patient. However, the optimal duration for this second treatment is not known.

Vagina_(mucosa) 2Healing remains uncertain for a considerable number of women, who must continue fluconazole for months or years, with a risk of non-compliance, and some patients cannot tolerate the proposed regimen. Moreover, the issue of resistance to azoles is important. So far, in these circumstances, the acquisition of resistance is very rare, although it is certainly reasonable to confirm the susceptibility of C.albicans to azoles in the absence of clinical response or failure to eradicate the pathogen agent from the body. In addition, for some authors, the long-term use of antifungals may increase the risk of bacterial vaginosis [MARTINEZ 2009]. Therefore, the management of this disease requires better-tolerated therapeutic agents and a better understanding of RVVC pathogenesis in order to provide alternative therapeutic approaches [SOBEL 2006].

Although the pathogenesis of VVC remains a controversial issue, it seems that when the balance of the vaginal microbiota is disrupted the proliferation of Candida is made easier, giving advocacy for the use of probiotics reestablishing this microbiota. However, it is commonly accepted that the effects of probiotics are strain-dependent: they cannot be extrapolated from one strain to another, even for the same species.

References

Sobel JD. Pathogenesis and epidemiology of vulvovaginal candidiasis. Ann NY Acad Sci 1988; 544: 547-57.
Sobel JD, Faro S, Force RW et al. Vulvovaginal candidiasis: epidemiologic, diagnostic and therapeutic considerations. Am J Obstet Gynecol 1998; 178: 203-11.
Sheary B, Dayan L. Recurrent vulvovaginal candidiasis. Aust Fam Physician 2005 Mar; 34(3): 147-50.
Sobel JD. Management of patients with recurrent vulvovaginal candidiasis. Drugs 2003; 63: 1059-66.
Sobel JD, Wiesenfeld HC, Martens M et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004; 351: 876-83.
Foxman B, Barlow R, d’Arcy H et al. Candida vaginitis: self-reported incidence and associated costs. Amer Sex Transm Dis Assoc 2000; 27: 230-5.
Fidel PL, Sobel JD. Immunopathogenesis of recurrent vulvovaginal candidiasis. Clin Microbiol Rev July 1996; 9 (3) : 335-48. Contracept Fertil Sex 1996 Jan; 24(1):33-40.
Watson C, Calbretto H. Comprehensive review of conventional and non-conventional methods of management of recurrent vulvovaginal candidiasis. Aust N Z J Obstet Gynaecol 2007 Aug; 47(4): 262-72.
Donders G, Bellen G, Byttebier G et al. Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial). Am J Obstet Gynecol 2008; 199:613.e1-e9.
Sobel JD. Management of recurrent vulvovaginal candidiasis: unresolved issues. Curr Infect Dis Rep 2006 Nov; 8(6): 481-6.
Jeavons H. Prevention and treatment of vulvovaginal candidiasis using exogenous Lactobacillus. J Obstet Gynecol Neonat Nurs 2003; 32 (3): 287-96.
Martinez RC, Franceschini SA, Patta MC et al. Improved treatment of vulvovaginal candidiasis with fluconazole plus probiotic Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14. Lett Appl Microbiol 2009; 48(3): 269-74.
Lachowsky M , Winaver D. Aspects psychosomatiques de la consultation en gynécologie  Elsevier Masson SAS 2007. Pages 213-4.

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