Topical treatment of recurrent vulvovaginal candidiasis: an expert consensus

A study published in Women’s Health Reports suggests best practices for treating recurrent vulvovaginal candidiasis.

A new consensus, published in Women’s Health Reports, offers a clear roadmap to mycologic (fungal) cure for the 1 in 10 women who suffer recurrent vulvovaginal candidiasis (RVVC)1 3 or more times yearly.

A panel of 5 ob-gyns2 specializing in RVVC met to develop guidelines for the condition’s effective and safe maintenance, given the lack of one offered by the US Centers for Disease Control and Prevention.

“The CDC does not provide recommendations for the type or frequency of topical maintenance, leaving clinicians without templates regarding best practice,” says lead author Nancy A. Phillips, MD,3 of Topical Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus.4

The group concluded that women with RVVC should be treated longer than those with non-recurrent VVC, starting with initial treatment of 7 to 14 days of topical therapy—versus 1-7 days—or 3 doses of fluconazole, with 100-, 150- or 200-mg. taken by mouth once every 3 days.

The type of yeast should be confirmed before treatment. Oral flucoconazole is ineffective against nonalbicans yeast, the cause of 1 in 5 fungal infections.

The doctors suggest 6 months of maintenance doses 1 to 3 times weekly—usually twice weekly—of topical azoles (clotrimazole, miconazole and terconazole) against C. albicans fungi and nonterconazole azole for nonalbicans fungi, unless terconazole worked for the patient previously.

Contributing factors to recurrent infections also should be addressed, such as intrauterine devices and diabetes. Ideally, diabetic patients should control blood sugar with drugs other than sodium glucose cotransporter two inhibitors (SGLT2).5 Corticosteroids and antibiotics should be minimized.

The panel also raised risks of some drugs.

Oral fluconazole can endanger women who are on statin drugs, have kidney disease or are at risk for arrhythmias.

It also can cause miscarriages. Indeed, a 2015 nationwide cohort study in Denmark showed a significantly higher chance of miscarriage and stillbirths in women taking oral fluconazole versus those who did not or who used a topical azole.6

Intravaginal boric acid and ibrexafungerp, an oral drug the US Food and Drug Administration approved last June,7 also can cause miscarriages.

Only 7-day azoles should be used during pregnancy or in women planning to become pregnant.

The 30-50% of women who continue to have recurrent infections after six months of maintenance treatment should see a RVVC specialist, the panel concludes.

References

  1. Foxman B, Muraglia R, Dietz JP, Sobel JD, Wagner J. Prevalence of recurrentvulvovaginal candidiasis in 5 European countries and the United States: Results from an internet panel survey. J Low Genit Tract Dis 2013;17:34
  2. Hope Haefner, MD, Department Obstetrics and Gynecology, University of Michigan University Hospital, Ann Arbor, Michigan, USA; Mark G. Martens, MD, Department Obstetrics and Gynecology, Tower Health, West Reading, Pennsylvania, USA; Colleen Stockdale, MD, MS, clinical professor in Obstetrics and Gynecology and director of Vulvar Vaginal Disease Clinic at Carver Medical School at University of Iowa, Iowa City, USA.
  3. Nancy A Phillips and Gloria Bachmann, MDs, Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
  4. Phillips NA, Bachmann G, Haefner H, Martens M, Stockdale C. Topical Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus. Womens Health Rep (New Rochelle). 2022 Jan 31;3(1):38-42. doi: 10.1089/whr.2021.0065. PMID: 35136875; PMCID: PMC8812501.
  5. Omudhome Ogbru, PharmD. SGLT2 Inhibitors (Type 2 Diabetes Drug Class). MedicineNet. Published July 2, 2019. Accessed March 22, 2022. https://www.medicinenet.com/sglt2_inhibitors_type_2_diabetes_drug_class/article.htm
  6. Mølgaard-Nielsen D, Svanstro ̈m H, Melbye M, Hviid A, Pasternak B., Association between use of oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth. JAMA 2016;315:58–67.
  7. Sakoulas, G., FDA Approves Ibrexafungerp (Brexafemme) for the Treatment of Vulvovaginal Candidiasis, NEJM Journal Watch, June 3, 2021.https://www.jwatch.org/na53719/2021/06/23/fda-approves-ibrexafungerp-brexafemme-treatment