In an early study, three days' treatment with 2% butoconazole vaginal cream was compared with a 7-day regimen of 2% miconazole vaginal cream in 271 women. After 30 days, 78% of the butoconazole-treated patients and 80% of the miconazole-treated patients remained free of vulvovaginitis. No difference in clinical and mycological cure or safety was found.27
In an RCT of prophylactic treatment, 38 of 42 patients (90-4%) who had achieved clinical cure with clotrimazole, 500 mg vaginal suppositories, continued to receive either 500 mg suppositories once monthly or placebo. Only a modest effect of the prophylactic regimen was evident.28
In another early placebo-controlled study, a singledose 500 mg clotrimazole vaginal suppository was compared with placebo. After 7-10 days, Candida was present in 21 (38%) of those treated with clotrimazole and in 30 (75%) in the placebo group (P<0-05). In questionnaires completed 4 weeks later, however, half the women in each group reported recurrence of vaginal symptoms.29
An interesting study investigated the relationship between female genital candidiasis and Candida colonisation of their partners. A total of 125 women experiencing an acute episode of recurrent candidal vaginitis were enrolled.30 Oral, penile and ejaculate cultures were also prepared from their male sexual partners. The rates of oral and rectal colonisation with Candida species in the women were 36% (45/125) and 45% (56/125), respectively. The male partners' oral cavities were positive in 23% (29/125) the penile coronal sulcus in 16% (20/125) and seminal fluid in 14% (18/125), respectively. In a follow up of 1 year, the clinical and microbiologic cure rate in the study group was 72% (95/125). The rate of relapse was not influenced by the treatment of Candida colonisation of the female intestinal tract, but the recurrence rate in the group with treatment of the sexual partner was lower (16% versus 45%, P= 0-0019).30 This is the first study to show that treatment of the partner had an effect whereas treatment of gut colonisation of the females did not.
No difference could be detected between 1% ciclopirox olamine and 0-8% terconazole vaginal cream in the treatment of genital candidiasis in 170 women in a multicentre RCT. Despite higher and not significantly different initial microbial and clinical cure rates in both arms, at the end of the follow up at day 42 the cure rates were only 32-5% for ciclopirox and 31-5% for terconazole.31
Newer studies have investigated the effect of topical sustained-release creams. Dellenbach etal. treated 183 women with a sertaconazole 300 mg suppository and 186 with an econazole 150 mg suppository in a multicentre, doubleblind RCT. The two groups did not differ in the rate of clinical recovery (disappearance of signs and symptoms) or mycological recovery (negative culture) 1 month after the last application (65-3 and 62-0%, respectively).32
What is the best treatment for vulvovaginal candidosis?
Del Palacio et al. enrolled 124 patients who were randomly allocated to receive single doses of 1%, 2% or 4% flutrimazole vaginal cream or placebo. The percentages of patients cured at 4 weeks were 60-6% 78-0% and 81-6% with 1%, 2% and 4% cream, and 48-4% with placebo. The differences in effectiveness between 2% and 4% flutrimazole and placebo were significant (P = 0-01 and P= 0-003, respectively).Treatment failure was significantly associated with isolation of C. glabrata.33
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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.