Insights and advances in recurrent vulvovaginal candidiasis

IntroductionAU : Pleaseconfirmthatallheadinglevelsarerepresentedcorrectly:Vulvovaginal candidiasis (VVC, colloquially referred to as a "yeast infection") is a vaginal fungal disease that is most common in females between 20 and 50 years old [1].The colloquial term "yeast" refers to the clinical syndrome and is the technical word for the typical morphology of the causative species.It is commonly stated that 75% of women will have at least 1 VVC episode, with 5% to 10% developing recurrent vulvovaginal candidiasis ("RVVC") [1].These statistics may underestimate the true incidence of R/VVC (i.e., referring to both VVC and RVVC).Recent global analyses of RVVC epidemiology estimated that 138 million women are annually affected [2,3].However, their analyses also highlighted that few to no robust global studies track women for at least 1 year with reliable clinical and microbiological data, and they hypothesize that prevalence and incidence are probably higher than assessed and increasing due to a growing at-risk population [2,3].R/VVC significantly affects morbidity and quality of life, with women incurring physical pain and elevated levels of depression and anxiety, including between symptomatic episodes [4].The economic impact on individuals and healthcare systems is also considerable, with global estimated losses of approximately $14 billion due to a decline in productivity [2,4].It is unclear why most VVC infections are successfully cleared after a single course of drug treatment, while a subset of women incur relapse of symptomatic episodes even during long-term maintenance treatment or after the cessation of therapy ([5] and references within).Whether symptomatic relapse is typically due to the population expansion of persistent vaginal yeast following treatment or reinfection remains unknown [6].Yeast can be a common member of the vaginal and gastrointestinal microbiome [7] without causing symptoms, further complicating our biological understanding of the interplay between vaginal yeast colonization and pathogenesis [8].Here, we discuss our current understanding of the etiology and diagnosis methods for R/ VVC and highlight exciting recent developments in the treatment landscape. Developments in Candida taxonomyR/VVC is caused by yeasts traditionally classified in the genus Candida.However, the genus Candida is highly polyphyletic, and several international taxonomic groups have recently endorsed reclassifying 25 species into 13 genera within the order Saccharomycetales [9-11].The proposed changes include Nakaseomyces (Candida) glabrata, the second most common species implicated in R/VVC (Fig 1).Concerns have been expressed about the impact of name changes on the compatibility with the published literature and the confusion it may generate in clinical practice; however, the name changes are likely far from many clinicians' radars.Approximately 85% to 95% of R/VVC episodes are caused by Candida albicans [6].

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