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h Abstract
Although recurrent vulvovaginal candidiasis
is defined as 4 or more discrete attacks of vulvovaginal
candidiasis per year, there is no diagnostic nomenclature or
definition for the many women who are chronically symptomatic. This study aims to establish and propose a definition and a set of diagnostic criteria, which would enable
clinicians to promptly identify and treat women with chronic
vulvovaginal candidiasis (CVVC).
Design. Prospective cohort study.
Setting. Public and private vulvar dermatology outpatient clinics in Sydney, Australia.
Participants. Data were obtained prospectively from
50 women with presumptive CVVC and 42 controls. Historical
and clinical features of CVVC identified by expert consensus
were compared between the 2 groups. Diagnostic criteria
were then prospectively applied to a further 163 patients to
verify their accuracy.
Outcome Measures. Signs and symptoms diagnostic
of CVVC.
Results. The following characteristics were found to be
significantly more common in women with CVVC compared
to controls (p e .001): a history of positive vaginal Candida
swab, discharge, dyspareunia, soreness, swelling, cyclicity,
and exacerbation of symptoms with antibiotics.
Objective.
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METHODS
Sign/symptom
Itch
History of improvement with antifungal treatment
Dyspareunia
Previous positive vaginal swab
Soreness
Cyclicity
Exacerbation with antibiotics
Discharge
Concordance, %
90
90
88
86
82
62
60
40
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RESULTS
The following items relating to signs and symptoms were
all significantly more common in the CVVC study cohort
compared to the control group (with p e .001): soreness,
dyspareunia, cyclicity, vulvovaginal swelling vaginal discharge, and positive vaginal swab for Candida. The following historical features were all significantly more
likely in the CVVC group (p G .001): history of previous
positive Candida vaginal swab while symptomatic, exacerbation of symptoms with oral antibiotics, and history
of improvement with any antifungal treatment even if
brief. At the follow-up visit, response to 3 months of oral
antifungal therapy was measured. All women with CVVC
had complete resolution of signs and symptoms with
prolonged daily oral antifungal treatment (p G .001). It
should be especially noted that 68% of the study group
and 7% of the control group had a positive swab at presentation. This is a significant difference; however, there
still remained 32% of patients who were fully responsive
to oral antifungal therapy who had a negative swab.
Eight clinical and historical features were identified as
being significantly more common in the CVVC group
(with high statistical significance, p e .001). Table 2
highlights odds ratios (ORs) associated with these features. Patients in the CVVC group were 79 times more
likely to have had a previous positive Candida swab than
women in the control group. Exacerbation with oral
antibiotics and vaginal discharge were more than
25 times more likely in patients with CVVC. Cyclicity of
symptoms and dyspareunia were 17 and 9 times more
likely in CVVC, respectively, whereas soreness and
92
92
86
92
88
92
92
92
(100)
(86.0)
(68.2)
(84.0)
(65.2)
(86.0)
(88.0)
(62.0)
(7.1)
(7.1)
(7.1)
(16.7)
(9.5)
(38.1)
(57.1)
(23.8)
OR (95% CI)
79.86
27.86
26.25
17.81
9.98
5.50
5.22
n/a
(19.30Y330.5)
(7.33Y105.8)
(8.66Y79.58)
(5.39Y58.88)
(3.63Y27.49)
(1.93Y15.71)
(2.10Y12.99)
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Diagnostic criteria
Previous response to antifungals
Previous or current positive swab
Exacerbation with antibiotics
Discharge
Cyclicity
Dyspareunia
Soreness
Swelling
139
133
126
102
131
153
146
103
(85.3)
(81.6)
(77.3)
(62.6)
(80.4)
(93.9)
(89.6)
(63.2)
Controls
(n = 42),
n (%)
3
3
3
7
4
16
24
10
(7.1)
(7.1)
(7.1)
(16.7)
(9.5)
(38.1)
(57.1)
(23.8)
p
G.0001
G.0001
G.0001
G.0001
G.0001
G.0001
G.0001
G.0001
DISCUSSION
CVVC seems to exist on a spectrum with acute and recurrent variants of VVC but presents as a different entity.
We propose that it be defined as a chronic nonerosive
vulvovaginitis causally related to Candida. These patients
symptoms are not recurrent but chronic and continuous,
remitting only during treatment with antifungal medication and frequently recurring rapidly on cessation. Our
results show that CVVC may be diagnosed using the
criteria set out in Table 3. This in turn results in the
ability to predict which patients will reliably benefit from
oral antifungal treatment.
Positive vaginal swabs were found in 68% of women
in the original study group and 81.6% of women in the
prospective group at the initial visit. Women with CVVC
in our study were found to have very low rates of positive
microscopy examinations for their swabs, and indeed, the
majority had completely normal microscopy. There are a
number of possible explanations for these results. The
ready availability of over-the-counter antifungal agents
used by patients who self-diagnose their CVVC may be
responsible. There are no data on how long antifungals
should be ceased for before a culture can become positive
again, and even if this were available, there is likely to be
a wide range between individuals. Women with CVVC
may also have lower Candida counts in the vaginal
epithelium that trigger symptoms compared to women
with more acute forms of VVC. Another possible but less
likely explanation is that the Candida strains found in
CVVC may differ to those implicit in more acute VVC
and may be more fastidious and difficult to culture. In
future studies of CVVC, it may be useful to use various
media other than CHROMagar for swab cultures and
polymerase chain reaction, which has not yet been shown
to be more sensitive than culture for Candida detection
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CONCLUSIONS
Patients presenting with chronic, erythematous nonerosive vulvovaginitis who answered yes to at least 5 of
the 8 criteria, which we identified as most characteristic
of this condition (Table 3), responded to a 3-month
course of oral antifungal medication with complete resolution of symptoms and signs in 100% of patients.
These criteria were subsequently verified in a further
group of 163 patients. This included patients with a
negative vaginal swab for Candida at presentation. We
propose that these diagnostic criteria may be useful in
correctly identifying patients who will be genuinely responsive to oral antifungal therapy and that CVVC
may be defined as a chronic nonerosive vulvovaginitis
causally associated with the antigenic effects of Candida.
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Copyright 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.