Clinical question
What is the most effective management for women with recurrent vulvovaginal candidiasis (≥ 4 episodes within 1 year)?
Bottom line
Prophylaxis with 6 months of azole therapy will reduce relapse to 9% to 19% of women compared with 50% to 64% with placebo (1 fewer woman would relapse for every 2 to 4 treated). However, efficacy declines after therapy cessation and clinical cure remains elusive. Limited evidence suggests women might prefer episodic over maintenance therapy.
Evidence
Two double-blind RCTs of 3731 and 64 women2 with symptoms and culture-confirmed recurrent vulvovaginitis compared 150 mg of oral fluconazole weekly for 6 months (after an initial 150 mg of oral fluconazole every 72 hours for 3 days) with placebo:
There was a statistically significant difference in clinical relapse rate:
At the 12-month follow-up,1 57% had relapsed versus 78% (NNT = 5). There was no significant difference in relapse in the smaller study,2 and no increase in resistance in either study.1,2
There was 1 case of “mild” elevation of liver enzymes that did not require treatment discontinuation.1
Analysis only included those compliant with treatment.1
Two RCTs examined 400 mg of oral itraconazole monthly (N = 114)3 and a monthly 500-mg clotrimazole vaginal suppository (N = 62)4 versus placebo for 6 months.
Statistically significant difference in clinical relapse rate: 30% to 36% versus 64% to 79%, NNT = 3 to 4.
One observational study of 136 women individualized decreasing doses (200 mg of fluconazole 3 times a week, weekly for 2 months, biweekly for 4 months, then monthly for 6 months) based on clinical symptoms5:
There was a 30% clinical relapse rate during 12 months of treatment and a 45% rate at the 18-month follow-up.
Context
Studies of alternative therapies, such as probiotics or homeopathy, are of poor quality and have mixed results.6
Limited evidence suggests no significant difference among azoles in acute or recurrent Candida albicans vulvovaginitis.7
Candida albicans causes 90% of vulvovaginal candidiasis, followed by Candida glabrata, which is azole resistant.8
A small trial (54 women) showed that treating male sexual partners with antifungals does not reduce relapse.9
A randomized crossover trial of 23 women reported 74% versus 14% prefer to treat each episode empirically versus maintenance therapy.10
Implementation
Only about one-third of women correctly self-diagnose vulvovaginal candidiasis.11 Yeast culture might be considered if the patient has recurrent infection, has treatment failure, or is immunocompromised. Small studies comparing boric acid (600 mg intravaginally daily for 7 to 14 days) with intravaginal nystatin or oral fluconazole suggest it has limited efficacy, particularly against C glabrata.12 Boric acid requires pharmacy compounding and might cause vulvovaginal irritation. There are no RCTs examining boric acid as prophylaxis.
Notes
Tools for Practice articles in Canadian Family Physician (CFP) are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in CFP are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.
Footnotes
Competing interests
None declared
The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.
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