The efficacy of the boric acid-based maintenance therapy in preventing recurrent vulvovaginal candidiasis

Abstract

Abstract Objective: Current gold-standard treatment of recurrent vulvovaginal candidiasis (RVVC) is mainly based on maintenance with fluconazole. Moderate to high recurrence rates at long-term use and secondary fluconazole resistance emerge seek for new topical maintenance regimens. In this study, it is aimed to assess the efficacy and safety of boric acid-based treatment approach to treat clinical RVVC. Material and methods: In this retrospective study, patients who were diagnosed with RVVC received a treatment package for six months that consist of induction with boric acid vaginal suppositories 600mg daily for 14 nights followed by maintenance for five nights starting with every fifth day of the menstrual cycles; a vaginal estriol-lactobacilli combination; and several rigorous life-style changes. The success was defined as the absence of symptomatic recurrence during the follow-up. Results: Success rate at the first year was found to be 94.8% in a total of 173 patients. Mild, reversible side effects were observed in five patients (2.9%). Conclusion: Boric acid, along with a vaginal estriol-lactobacilli combination and life style changes can be a safe and effective alternative in lieu of potent systemic antifungal drugs as a first-line treatment for the patients referred with RVVC.

Keywords

• boric acid
• life style changes
• recurrent vulvovaginal candidiasis
• vaginal flora

References

1. 1. Matheson A, Mazza D. Recurrent vulvovaginal candidiasis: a review of guideline recommendations. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017;57(2):139-145.
2. 2. Denning DW, Kneale M, Sobel JD, Rautemaa-Richardson R. Global burden of recurrent vulvovaginal candidiasis: a systematic review. The Lancet Infectious Diseases. 2018;18(11):e339-e347.
3. 3. Foxman B, Muraglia R, Dietz J-P, Sobel JD, Wagner J. Prevalence of recurrent vulvovaginal candidiasis in 5 European countries and the United States: results from an internet panel survey. Journal of lower genital tract disease. 2013;17(3):340-345.
4. 4. Rao VL, Mahmood T. Vaginal discharge. Obstetrics, Gynaecology & Reproductive Medicine. 2019.
5. 5. Sobel JD. Recurrent vulvovaginal candidiasis. American journal of obstetrics and gynecology. 2016;214(1):15-21.
6. 6. Ramírez-Lozada T, Espinosa-Hernández VM, Frías-De-León MG, Martínez-Herrera E. Update of Vulvovaginal Candidiasis in Pregnant and Non-pregnant Patients. Current Fungal Infection Reports. 2019;13(4):181-190.
7. 7. Donders G, Bellen G, Byttebier G, et al. Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial). American journal of obstetrics and gynecology. 2008;199(6):613. e611-613. e619.
8. 8. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. New England Journal of Medicine. 2004;351(9):876-883.

9. 9. Marchaim D, Lemanek L, Bheemreddy S, Kaye KS, Sobel JD. Fluconazole-resistant Candida albicans vulvovaginitis. Obstetrics & Gynecology. 2012;120(6):1407-1414.
10. 10. Sobel J, Sobel R. Current treatment options for vulvovaginal candidiasis caused by azole-resistant Candida species. Expert opinion on pharmacotherapy. 2018;19(9):971-977.
11. 11. Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. American journal of obstetrics and gynecology. 2003;189(5):1297-1300.
12. 12. Iavazzo C, Gkegkes ID, Zarkada IM, Falagas ME. Boric acid for recurrent vulvovaginal candidiasis: the clinical evidence. Journal of Patients's Health. 2011;20(8):1245-1255.
13. 13. De Seta F, Schmidt M, Vu B, Essmann M, Larsen B. Antifungal mechanisms supporting boric acid therapy of Candida vaginitis. Journal of Antimicrobial Chemotherapy. 2009;63(2):325-336.
14. 14. Córdoba S, Taverna C, Vivot W, et al. Emergence of Resistance to Fluconazole in Candida albicans Isolated From Vaginal Discharge. Current Fungal Infection Reports. 2018;12(4):155-160.
15. 15. Aznar-Marin P, Galan-Sanchez F, Marin-Casanova P, García-Martos P, Rodríguez-Iglesias M. Candida nivariensis as a new emergent agent of vulvovaginal candidiasis: description of cases and review of published studies. Mycopathologia. 2016;181(5-6):445-449.
16. 16. Powell A, Ghanem KG, Rogers L, et al. Clinicians' Use of Intravaginal Boric Acid Maintenance Therapy for Recurrent Vulvovaginal Candidiasis and Bacterial Vaginosis. Sexually transmitted diseases. 2019;46(12):810-812.
17. 17. Thorley N, Ross J. Intravaginal boric acid: is it an alternative therapeutic option for vaginal trichomoniasis? Sexually transmitted infections. 2018;94(8):574-577.
18. 18. Schmidt M, Tran-Nguyen D, Chizek P. Influence of boric acid on energy metabolism and stress tolerance of Candida albicans. Journal of Trace Elements in Medicine and Biology. 2018;49:140-145.
19. 19. Beach T, Hart B, Larsen B. Stress response in Candida albicans induced by boric acid. Journal of Advances in Medicine and Medical Research. 2016:1-11.
20. 20. 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. American journal of obstetrics and gynecology. 2001;184(4):598-602.
21. 21. Reichman O, Akins R, Sobel JD. Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis. Sexually transmitted diseases. 2009;36(11):732-734.
22. 22. Ozkinay E, Terek MC, Yayci M, Kaiser R, Grob P, Tuncay G. The effectiveness of live lactobacilli in combination with low dose oestriol (Gynoflor) to restore the vaginal flora after treatment of vaginal infections. BJOG: An International Journal of Obstetrics & Gynaecology. 2005;112(2):234-240.
23. 23. van de Wijgert JH, Verwijs MC. Lactobacilli‐containing vaginal probiotics to cure or prevent bacterial or fungal vaginal dysbiosis: a systematic review and recommendations for future trial designs. BJOG: An International Journal of Obstetrics & Gynaecology. 2020;127(2):287-299.
24. 24. Thomas-White K, Brady M, Wolfe AJ, Mueller ER. The bladder is not sterile: history and current discoveries on the urinary microbiome. Current bladder dysfunction reports. 2016;11(1):18-24.
25. 25. Gottschick C, Deng Z-L, Vital M, et al. The urinary microbiota of men and patients and its changes in patients during bacterial vaginosis and antibiotic treatment. Microbiome. 2017;5(1):99.