Perspectives on Vaginal Ecology and Management of Recurrent Vulvovaginal Candidiasis: A Narrative Review

Vulvovaginal candidiasis (VVC) affects around three quarters of women at least once in their lifetime. Around 10% of these women will experience prolonged or recurrent vulvovaginal candidiasis (RVVC) which fails to respond despite following recommended therapy. Most commonly prescribed therapy involves suppression therapy for usually two weeks which aims at eliminating symptoms by frequent administration of antifungals, followed by maintenance (weekly / monthly) therapy for up to six months. However, following cessation of maintenance therapy, around 50% of these women experience relapse. The vaginal ecology of RVVC can be characterized and it is thought that biofilms and/or the development of antifungal resistance prevent adequate resolution. However, hypersensitivity may also confound management. This review examines the management of VVC and the challenges of current prolonged antifungal therapy. It remains important to investigate the microbiological findings in RVVC and how these may inform rational choices in therapy in an era of rising antimicrobial resistance. Hope exists that studies of the vaginal microbiome highlight that the type of microbiota present may influence the level of inflammation and reduce symptomatology. Future research will continue to explore whether a personalized medicine approach can promote healthy vaginal ecology and prevent the debilitating long-term effects of RVVC.