Review of antifungal options for vulvovaginal candidiasis in women of reproductive age

Vulvovaginal candidiasis (VVC), predominantly caused by Candida albicans, is one of the most common vaginal infections in women of reproductive age. Its clinical management has become increasingly complex due to the rising prevalence of non-albicans Candida infections, escalating azole resistance, and the challenge of biofilm formation. This review systematically summarizes recent advances in VVC research, with a focus on evolving epidemiology, innovations in diagnostics, current and emerging therapies, and an in-depth analysis of resistance mechanisms. Key molecular pathways underpinning antifungal resistance—including biofilm development, efflux pump overexpression, target-site gene mutations, and alterations in transcriptional regulators—are examined. The findings of this review support several actionable strategies for future practice. First, routine use of molecular diagnostics (PCR, MALDI-TOF MS) is essential for species identification and resistance detection, enabling a shift from empirical to precision-based therapy. Second, antifungal susceptibility testing should be interpreted with attention to vaginal pH conditions, and non-azole alternatives (boric acid, nystatin, ibrexafungerp, oteseconazole) should be prioritized when azole resistance is confirmed or suspected. Third, emerging approaches—including biofilm-disrupting agents, probiotic microbiome modulation, and nanotechnology-enhanced drug delivery—offer promising adjunctive and preventive strategies, particularly for recurrent VVC. By integrating these contemporary findings, this review provides a translational framework to optimize diagnosis, guide therapeutic decision-making, and inform future research priorities in VVC management. Notably, several novel agents—including ibrexafungerp and oteseconazole—have already received FDA approval and are entering clinical practice, with multiple ongoing trials evaluating boric acid, probiotics, and novel oral antifungals, underscoring the accelerating translation of mechanism-informed therapies into patient care.