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Recurrent Vulvovaginal Candidiasis: Suppression by Fluconazole

For women with recurrent vulvovaginal candidiasis, long-term weekly fluconazole therapy can reduce the recurrence rate.

Recurrent vulvovaginal candidiasis occurs in 5% to 8% of premenopausal women, prompting frequent physician visits. Prophylactic antifungal therapies have reduced recurrence rates but are inconvenient and expensive; long-term oral ketoconazole use also can induce hepatotoxicity. Researchers recently conducted an industry-funded, randomized, double-blind trial of long-term fluconazole treatment in 387 immunocompetent women with recurrent vulvovaginal candidiasis (4 episodes annually), mostly due to Candida albicans.

Initially, all women received fluconazole (three 150-mg doses, 3 days apart) to produce clinical remission. Thereafter, they received suppressive fluconazole (150 mg) or placebo once weekly for 6 months, then were observed without therapy for 6 months. Clinical remission was maintained at 6, 9, and 12 months in 90.8%, 73.2%, and 42.9% of fluconazole recipients and in 35.9%, 27.8%, and 21.9% of placebo recipients (all P<0.001). Median time to clinical recurrence was 10.2 months in actively treated women and 4.0 months in placebo recipients; median time to mycologic relapse was 8.4 and 1.9 months, respectively. No fluconazole-resistant strains of C. albicans developed, nor did superinfections develop with other candida species; fluconazole was tolerated well.

Comment: Suppressive therapy with fluconazole works for recurrent vulvovaginal candidiasis and, according to an editorialist, now should be considered the standard of care. However, additional data are needed on the efficacy and safety of therapy lasting >6 months. Fluconazole usually fails to provide long-term cures. A better understanding of candida virulence factors and of the role of mucosal immunity in infected women is needed before this condition can be better controlled or eradicated.

— Neil R. Blacklow, MD

Published in Journal Watch Infectious Diseases September 10, 2004

Citation(s):

Sobel JD et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004 Aug 26; 351:876-83.

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Eschenbach DA. Chronic vulvovaginal candidiasis. N Engl J Med 2004 Aug 26; 351:851-2.

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• Medline abstract (Free)