Canadian Guidelines on Sexually Transmitted Infections

http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-4-8-eng.php

Table 6. Treatment of recurrent vulvovaginal candidiasis (RVVC)

Induction treatment

• Fluconazole 150 mg PO once every 72 hours for three doses [A-l].^Footnote34 Efficacy 92%. Contraindicated in pregnancy
• Topical azole for 10–14 days [B-ll]^{Footnote35–Footnote38}
• Boric acid 300–600 mg gelatin capsule intravaginally once a day for 14 days [B-ll]^{Footnote39,Footnote40} Less mucosal irritation experienced when 300 mg used.^Footnote40 Efficacy approximately 80%.^Footnote40 Contraindicated in pregnancy

Notes:

• Each individual episode of RVVC caused by C. albicans usually responds to a course of oral or topical azoles, with a longer course usually more effective than a shorter one.^Footnote36
• Without maintenance therapy, VVC recurs in 50% of patients within 3 months.
• Start maintenance therapy as soon as initial treatment has been completed.

Maintenance treatment

• Fluconazole 150 mg PO once a week [A-l].^Footnote34 Recurrence occurred in 10% while receiving therapy
• Ketoconazole 100 mg PO once a day [A-l].^Footnote41 Recurrence occurred in 5% while receiving therapy. Patients receiving long-term ketoconazole should be monitored for hepatotoxicity (incidence one in 12,000)
• Itraconazole 200–400 mg PO once a month [A-l].^{Footnote42,Footnote43} Recurrence occurred in 36% while receiving therapy^Footnote43
• Clotrimazole 500 mg intravaginally once a month [A-l]^Footnote44
• Boric acid 300 mg capsule intravaginally for 5 days each month beginning the first day of the menstrual cycle [B-ll].^Footnote40 Recurrence occurred in 30% while receiving therapy^Footnote40

Notes:

• Duration of maintenance therapy is a minimum of 6 months. After 6 months, discontinue therapy and observe.
• Relapse rate is high, with approximately 60% of women relapsing within 1–2 months of discontinuing maintenance therapy.^{Footnote8,Footnote36}
• If recurrence occurs, treat the episode and then reintroduce a maintenance regimen.
• Fluconazole and boric acid are contraindicated in pregnancy.
• Oil-based ovules and creams may cause latex condoms or diaphragms to fail.

RVVC: recurrent vulvovaginal candidiasis

VVC: vulvovaginal candidiasis

Table 8. Treatment of non-albicans vulvovaginal candidiasis

Non-albicans VVC

• Most commonly due to C. glabrata, which is 10- to 100-fold less susceptible to azoles than C. albicans.^Footnote8

Initial treatment

• Boric acid 600 mg capsule intravaginally once a day for 14 days [B-ll].^{Footnote38,Footnote39,Footnote45,Footnote46} Efficacy 64–81%. Vaginal burning reported in <10%
• Flucytosine cream 5 g intravaginally once a day for 14 days [B-ll].^{Footnote46,Footnote47} Efficacy 90%
• Amphotericin B 50 mg suppository intravaginally once a day for 14 days [B-lll].^Footnote48Efficacy 80% (10 patients). Mild external irritation reported in 10%
• Flucytosine 1 g PLUS amphotericin B 100 mg (combined in a lubricating jelly) administered intravaginally once a day for 14 days [B-lll].^{Footnote49,Footnote50} Efficacy 100% (in 4 patients)

If symptoms recur

• Retreat with boric acid 600 mg capsule intravaginally once a day for 14 days FOLLOWED BY: alternate-day boric acid for several weeks or 100,000 units of nystatin vaginal suppositories once a day for 3-6 months [B-lll] ^Footnote8

Note:

• No safety data available for long-term use of boric acid.^Footnote51

Compromised host

• Corticosteroids, uncontrolled diabetes.
• C. glabrata and other non-albicans species are isolated more frequently in women with diabetes than in those without.
• Treat with a longer (10–14 day) course of an intravaginal azole [B-lll] OR boric acid 600 mg capsule intravaginally once a day for 14 days [B-ll].^{Footnote37,Footnote38}

Boric acid vaginal suppositories: a brief review (full PDF)

Prutting SM, Cerveny JD. Infect Dis Obstet Gynecol. 1998;6(4):191-4.

Source: Medical College of South Carolina, Charleston, USA.

Boric acid for recurrent vulvovaginal candidiasis: the clinical evidence

Iavazzo C, Gkegkes ID, Zarkada IM, Falagas ME. J Womens Health (Larchmt). 2011 Aug;20(8):1245-55. doi: 10.1089/jwh.2010.2708. Epub 2011 Jul 20.

Source

Alfa Institute of Biomedical Sciences, 9 Neapoleos Street, Marousi, Athens, Greece.

Abstract

BACKGROUND: Recurrent vulvovaginal candidiasis (VVC) remains a challenge to manage in clinical practice. Recent epidemiologic studies indicate that non-albicans Candida spp. are more resistant to conventional antifungal treatment with azoles and are considered as causative pathogens of vulvovaginal candidiasis.

METHODS: We searched PubMed and Scopus for studies that reported clinical evidence on the intravaginal use of boric acid for vulvovaginal candidiasis.

RESULTS: We identified 14 studies (2 randomized clinical trials [RCTs], 9 case series, and 4 case reports) as eligible for inclusion in this review. Boric acid was compared with nystatin, terconazole, flucytosine, itraconazole, clotrimazole, ketoconazole, fluconazole, buconazole, and miconazole; as monotherapy, boric acid was studied in 7 studies. The mycologic cure rates varied from 40% to 100% in patients treated with boric acid; 4 of the 9 included case series reported statistically significant outcomes regarding cure (both mycologic and clinical) rates. None of the included studies reported statistically significant differences in recurrence rates. Regarding the adverse effects caused by boric acid use, vaginal burning sensation (<10% of=”” cases=”” water=”” discharge=”” during=”” treatment=”” and=”” vaginal=”” erythema=”” were=”” identified=”” in=”” 7=”” studies=”” span=””>

CONCLUSIONS: Our findings suggest that boric acid is a safe, alternative, economic option for women with recurrent and chronic symptoms of vaginitis when conventional treatment fails because of the involvement of non-albicans Candida spp. or azole-resistant strains.

Prevalence of Candida glabrata and its response to boric acid vaginal suppositories in comparison with oral fluconazole in patients with diabetes and vulvovaginal candidiasis

Ray D, Goswami R, Banerjee U, Dadhwal V, Goswami D, Mandal P, Sreenivas V, Kochupillai N. Diabetes Care. 2007 Feb;30(2):312-7.

Source

Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi 110029, India.

Abstract

OBJECTIVE: A large proportion of vulvovaginal candidiasis (VVC) in diabetes is due to non-albicans Candida species such as C. glabrata and C. tropicalis. Observational studies indicate that diabetic patients with C. glabrata VVC respond poorly to azole drugs. We evaluated the response to oral fluconazole and boric acid vaginal suppositories in diabetic patients with VVC.

RESEARCH DESIGN AND METHODS: A total of 112 consecutive diabetic patients with VVC were block randomized to receive either single-dose oral 150-mg fluconazole or boric acid vaginal suppositories (600 mg/day for 14 days). The primary efficacy outcome was the mycological cure in patients with C. glabrata VVC in the two treatment arms. The secondary outcomes were the mycological cure in C. albicans VVC, overall mycological cure irrespective of the type of Candida species, frequencies of yeast on direct microscopy, and clinical symptoms and signs of VVC on the 15th day of treatment. Intention-to-treat (ITT; n = 111) and per-protocol (PP; n = 99) analyses were performed.

RESULTS: C. glabrata was isolated in 68 (61.3%) and C. albicans in 32 (28.8%) of 111 subjects. Patients with C. glabrata VVC showed higher mycological cure with boric acid compared with fluconazole in the ITT (21 of 33, 63.6% vs. 10 of 35, 28.6%; P = 0.01) and PP analyses (21 of 29, 72.4% vs. 10 of 30, 33.3%; P = 0.01). The secondary efficacy outcomes were not significantly different in the two treatment arms in the ITT and PP analyses.

CONCLUSIONS: Diabetic women with C. glabrata VVC show higher mycological cure with boric acid vaginal suppositories given for 14 days in comparison with single-dose oral 150-mg fluconazole.

Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis

Reichman O, Akins R, Sobel JD. Sex Transm Dis. 2009 Nov;36(11):732-4. doi: 10.1097/OLQ.0b013e3181b08456.

Source

Division of Infectious Disease, Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA.

Abstract

BACKGROUND: Recurrent bacterial vaginosis (RBV) is extremely common and a source of frustration to patient and practitioners alike. In the absence of curative therapy, practitioners resort to retreating each individual episode. It has been suggested that vaginal biofilm in BV facilitates persistence of bacterial pathogens. Accordingly, topical boric acid (BA) aimed at biofilm removal was added to nitroimidazole induction and maintenance therapy creating a triple phase regimen to reduce symptomatic recurrence of BV in high-risk patients.

METHOD: Uncontrolled, nonrandomized, retrospective chart review of patients with RBV treated with 7 days of oral nitroimidazole; followed by 21 days of intravaginal BA 600 mg/day and if in remission treated with metronidazole gel twice weekly for 16 weeks. Outcome was determined using Amsel criteria.

RESULTS: Fifty-eight women were treated for a total of 77 episodes of RBV. Sixty episodes of BV were available for a follow-up evaluation 4 to 12 weeks after enrollment, having completed both nitroimidazole and BA therapy and before initiating vaginal metronidazole gel. Cure after nitroimidazole and BA therapy ranged from 88% to 92%, 7 and 12 weeks after the initial visit, respectively. Cumulative cure at 12, 16, and 28 weeks from initial visit was 87%, 78%, and 65%, respectively. A failure rate of 50% was documented by 36 weeks of follow-up. No adverse effects of BA were observed.

CONCLUSION: Clinical experience with a triple phase maintenance regimen for women with RBV was encouraging but requires validation in a prospective randomized controlled study.

Other References:

Van Slyke KK, Michel VP, Rein MF. Treatment of vulvovaginal candidiasis with boric acid powder. Am J Obstet Gynecol. 1981;141(2):145-148.[PubMed 7282789]

Swate TE, Weed JC. Boric acid treatment of vulvovaginal candidiasis. Obstet Gynecol. 1974;43(6):893-895.[PubMed 4597792]

Guaschino S, De Seta F, Sartore A, et al. Efficacy of maintenance therapy with topical boric acid in comparison with oral itraconazole in the treatment of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol. 2001;184(4):598-602.[PubMed 11262459]

Jovanovic R, Congema E, Nguyen HT. Antifungal agents vs. boric acid for treating chronic mycotic vulvovaginitis. J Reprod Med. 1991;36(8):593-597.[PubMed 1941801]

Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol. 2003;189(5):1297-1300.[PubMed 14634557]

Sobel JD, Chaim W. Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy. Clin Infect Dis. 1997;24(4):649-652.[PubMed 9145739]

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