Vulvovaginal Candidosis: Current Concepts, Challenges and Perspectives Original paper

What was reviewed?

This paper provides a comprehensive narrative review of vulvovaginal candidosis (VVC), focusing on the current concepts, challenges, and perspectives related to the epidemiology, pathogenesis, and diagnosis of this common fungal infection. It systematically synthesizes existing literature on the prevalence, microbial factors, host-pathogen interactions, diagnostic approaches, and virulence mechanisms of Candida species, particularly Candida albicans, the primary pathogen implicated. The review excludes treatment strategies but highlights the clinical burden and research gaps that remain in understanding VVC.

Who was reviewed?

The review draws on a broad spectrum of studies encompassing symptomatic and asymptomatic women of reproductive age worldwide. It includes epidemiological data from various countries, microbiological characterizations of Candida species isolated from vaginal samples, and immunological studies investigating host responses to Candida colonization and infection. The reviewed populations primarily consist of immunocompetent women, with an emphasis on those experiencing acute and recurrent vulvovaginal candidosis (RVVC).

What were the most important findings?

The review underscores that VVC affects approximately 70-75% of women at least once in their lifetime, with 5-8% developing recurrent episodes (RVVC). Candida albicans dominates as the causative species in 90-95% of infections, while non-albicans species, such as C. glabrata, C. tropicalis, and others, cause milder infections. The transition from Candida colonization to pathogenic infection involves complex virulence factors, including adhesins from the ALS gene family (notably ALS1-3 and ALS9), hydrolytic enzymes like secreted aspartyl proteinases (Saps), and phospholipases, which enhance fungal adherence, tissue invasion, and immune evasion. The formation of hyphae and the secretion of candidalysin toxin are crucial for tissue damage and immune activation. Host immune responses, including neutrophil recruitment and inflammasome activation, also critically shape disease outcomes.

Diagnostic challenges arise because colonization does not always equate to infection; microscopy detects hyphae in only 50-80% of cases, and culture or molecular methods improve sensitivity. Furthermore, over-the-counter self-treatment without proper diagnosis often leads to ineffective management and potential antifungal resistance. The review also highlights that Candida forms biofilms, which may contribute to antifungal resistance in vaginal infections, though researchers have yet to fully elucidate its exact role in VVC. The vaginal mycobiome in asymptomatic women is more diverse than previously appreciated, indicating a need to differentiate commensalism from pathogenic states more clearly.

What are the greatest implications of this review?

This review emphasizes the critical need for improved diagnostic accuracy to distinguish colonization from infection and prevent unnecessary or inappropriate antifungal use that drives resistance. It signals that future research should focus on the molecular mechanisms of Candida virulence, host-pathogen interactions, and the role of biofilms to identify new therapeutic targets. The growing understanding of the vaginal mycobiome and its complexity calls for integrative microbiome-based diagnostics and personalized treatment strategies. Furthermore, the review advocates for intensified research efforts and clinical awareness of VVC as a significant and neglected women’s health issue, encouraging the exploration of alternative therapies, including probiotics and vaccination, which show promise in preclinical studies. Ultimately, better integration of microbiome insights into clinical practice will enhance patient outcomes and management of vulvovaginal candidosis.