What to do with the patient with recurrent vulvovaginal candidiasis.

The problem Genital infection with candida species is common in women, 75% of whom will have had at least one episode during their lives. Indeed, there is a 15–20% point prevalence of asymptomatic candida carriage in young, nonpregnant, premenopausal women. While acute episodes of candidal vulvovaginitis usually respond rapidly to treatment, some women suVer frequent recurrences or chronic infection and, usually, no predisposing factors can be identified. Recurrent vulvovaginal candidiasis (RVVC) may be defined as four attacks of mycologically proved candidiasis within 12 months. With asymptomatic carriage there are only small numbers of yeasts (<10/ml), usually in the blastospore (budding) form. Transition to the hyphal form is associated with symptomatic disease. Although an individual may be culture negative after treatment, yeasts may not be totally eliminated and “vaginal relapse” may occur, usually with the same strain. It is important, however, to be certain that symptoms are caused by candida; a vaginal swab may be negative but candida can be found on the vulva which is the more common site of symptoms. Here candida needs to be distinguished from a raft of dermatological problems including seborrhoeic dermatitis, eczema, lichen sclerosus et atrophicus, hypersensitivity vulvitis, and psoriasis, among others.