Sobel JD
Wayne State University, DETROIT, USA
Vulvovaginal candidiasis (VVC) remains an extremely common clinical syndrome: surveillance studies indicate its continued high prevalence in all strata of society. A possible increase in the incidence of non-albicans Candida has been reported. Reasons for this shift include abuse of over-the-counter (OTC) products as well as short, abbreviated courses of oral and topical antimycotics. Clinicians today must deal with an extensive armamentarium of highly effective local and systemic antimycotic agents for the treatment of vulvovaginal candidiasis. In the past few years, several topical agents of equal efficacy have become available over the counter, offering women direct access to treatment. More than 50% of episodes of putative VVC are treated with OTC topical agents without practitioner involvement. Local topical therapy is available in several formulations and dosage regimens. Little or no evidence exists that one formulation is superior to another or that systemic therapy is superior to topical therapy. Duration of therapy is another major variable. All topical azoles available by prescription have been reformulated to shorten the regimen from 7 days to 1 day. These new formulations use higher dose inserts to extend the duration of local activity of the antimycotic. In this highly competitive market, prescription regimens are now rarely longer than 3 days, and reformulation of OTC products is being considered to shorten regimens. Fluconazole, is a one-dose oral regimen and has been shown to be as effective as 7-day topical clotrimazole and miconazole for uncomplicated VVC. What determines therapeutic efficacy-total duration or total dose of therapy? Moreover "single-dose" does not mean "single-day" therapy; a single dose (eg, fluconazole 150 mg by mouth or clotrimazole 500 mg in suppository form) provides effective vaginal levels of antimycotic for several days. These issues are key to the treatment of VVC because episodes of infection are not equal in severity and duration, nor are they cause by equally susceptible micro-organisms. Another important variable in the management of VVC is the role of compliance in determining clinical response and the risk of recurrence. A new approach to management is based on a recently introduced classification of VVC that distinguishes complicated from uncomplicated infections. Uncomplicated VVC refers to the more prevalent C albicans infections that are infrequent, are of mild-to-moderate severity, and occur in a normal host. Uncomplicated infections respond readily to all forms of both topical and oral therapy, including short-course or single-day antimycotic regimens. In contrast, complicated VVC refers to infections in which factors related to the micro-organism or host necessitates more intensive and prolonged therapy. Patients with complicated VVC may have severe infections, a history of recurrent VVC, or infection caused by a non-albicans Candida species; they may be more prone to such risk factors as uncontrolled diabetes mellitus or compromised immune function. These patients are far less likely to respond to short-course therapy. Recently a randomized controlled study confirmed that women with severe vaginitis enjoyed a significant therapeutic benefit from a 2nd dose of fluconazole added 72 hours after the first dose. The availability of a variety of therapeutic options allows for a management approach based on the patient’s individual needs and preferences.