New Treatments for Vulvovaginal Candidiasis

ulvovaginal candidiasis (VVC) is probably the most common form of vaginal infection, although bacterial vaginosis is believed to be more frequent. 1,z Even though Candida assumes a role as a pathogen, it is an opportunistic organism causing systemic infections usually in patients who are immunosuppressed or critically ill on multiple antibiotics. However, several studies have demonstrated that C. albicans is a member of the host’s endogenous vaginal and gastrointestinal microflora. Auger and Jolly3 isolated Candida from approximately 70% of healthy women. Other investigators have isolated C. albicans from the lower genital tracts of healthy, asymptomatic women with a frequency of 5-55%. It is estimated that 75% of all women will experience one episode of symptomatic VVC during their lifetime.7,8 Unfortunately, 40-50% of women will have at least one recurrence of VVC and at least 5% will have chronic or repeated episodes of VVC. Perhaps this condition should be viewed as a disturbance in the vaginal ecosystem rather than a disease in view of the fact that Candida is part of the complex endogenous microflora of many individuals. Alterations in the vaginal ecosystem can be favorable to the growth of C. albicans and other species. Once the yeast becomes dominant, it may result in a symptomatic condition and even produce findings consistent with acute infection. No doubt, the symptomatic condition is extremely prevalent, as evidenced by the 13 million prescriptions written in the United States between 1980 and 1990.1 While C. albicans is the predominant yeast, causing 85-90% of all cases of VVC, information is slowly being accumulated on a rising incidence of VVC due to non-albicans species such as C. (Torulopsis) glabrata, C. tropicalis, and C. krusei (Table 1).9 This rising incidence has become even more of a concern in view of the availability of several antimycotic agents that no longer require a prescription (over-the-counter products). The easy accessibility of antimycotic intravaginal preparations has raised at least three major concerns: 1) The wanton or indiscriminate use of these agents may exert selective pressure for resistant strains; 2) the indiscriminate use of these agents may allow for replacement by other species such as C. glabrata, C. tropicalis, or C. krusei; and 3) the treatment may be misdirected if the individual has another or concomitant infection. Added to these concerns is the fact that the