Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis

Millions of women worldwide continue to suffer from vulvovaginal candidiasis, which is second only to anaerobic bacterial vaginosis in the United States. Evidence is presented of an increasing incidence of vulvovaginal candidiasis, the cause of which is unclear, but this increase is probably the result of multiple factors including widespread abuse of antibiotics, possibly oral contraceptives, and most important inadequate vaginal therapy. Some women never experience vulvovaginal candidiasis, others have infrequent episodes, and a third subpopulation have recurrent episodes resulting in considerable morbidity and suffering. Two fundamental questions face investigators: the mechanism whereby asymptomatic colonization converts to symptomatic disease and the elusive explanation for frequent recurrences of vulvovaginal candidiasis. Although several factors have been identified as predisposing to recurrent vulvovaginal candidiasis (pregnancy, oral contraceptives, exogenous hormones, antibiotics, diabetes mellitus, etc.), the majority of women with recurrent vulvovaginal candidiasis do not have recognizable predisposing factors. What has emerged over the last few years is the awareness that different pathogenic mechanisms may be operative in individual patients responsible for a spectrum of clinical manifestations. Understanding the pathogenic mechanisms is essential if we are to progress in treatment. In addition to the study of newer antimycotic agents, new strategies of therapy are required and must be individualized for patients with recurrent vulvovaginal candidiasis.