Introduction

Vulvovaginal candidiasis (VVC) is a common condition and usually straightforward to treat. In contrast, complicated VVC can be intractable and cause considerable psychological morbidity. Complicated VVC includes recurrent or severe disease, or when there are adverse factors in the host.1 This includes persistent infection with species other than Candida albicans (‘non-C albicans’) and the more common recurrent albicans VVC. The importance of distinguishing the two conditions is that non-C albicans chronic vaginal yeast infection is potentially completely curable, but may need a different approach in terms of treatment modalities.2–7 This article suggests a stepwise approach to treatment using the best current evidence and the clinical experience of the authors and focuses on C glabrata since this species is responsible for the majority of cases. Other species and indeed other genera such as Saccharomyces cerevisiae can also be involved but less frequently (see supplementary table 1).

Vaginal infection with non-C albicans may occur at any age and series from India and elsewhere suggest that uncontrolled type 2 diabetes is a risk factor.8 Symptoms may sometimes stretch back over many years with a long history of misdiagnosis and frustration. At least one swab identified to species level is an essential part of the diagnostic workup of any woman presenting with chronic or persistent vaginitis. Usually, but not always, the yeast is present in large amounts and is visible on microscopy. In the event of a positive swab a repeat sample should be sent to confirm. Relatively asymptomatic cases occur and clinically it can sometimes be difficult to be sure how much of a contributor the organism is to symptoms. This is sometimes only clear after eradication and even then symptoms can be very slow to settle.