FPIN's Clinical Inquiries

Probiotics to Augment Antifungal Treatment of Vulvovaginal Candidiasis


Am Fam Physician. 2020 Apr 1;101(7):432-433.

Clinical Question

How effective are probiotics for augmenting antifungal treatment of vulvovaginal candidiasis?

Evidence-Based Answer

Adding probiotics (typically Lactobacillus species) to antifungal therapy for vulvovaginal candidiasis improves short-term cure rates by 14% and reduces one-month relapse rates by 66%. (Strength of Recommendation [SOR]: B, based on a meta-analysis of low-quality randomized controlled trials [RCTs].) Adding probiotics to antifungal therapy for women with recurrent vulvovaginal candidiasis may improve long-term cure rates over three to six months. (SOR: C, based on a small RCT that conflicted with low-quality RCTs.)

Evidence Summary

A 2017 Cochrane review of five low-quality RCTs (n = 695) found that adding probiotics to antifungal regimens increased the short-term clinical cure rate in women with vulvovaginal candidiasis.1 The studies included nonpregnant Chinese and Iranian women 16 to 50 years of age. The diagnosis of vulvovaginal candidiasis was initially made symptomatically, then confirmed by microscopy. Women with recurrent vulvovaginal candidiasis, diabetes mellitus, immunosuppression, or evidence of coinfections were excluded. Patients were randomized to antifungal therapy alone or antifungals plus probiotics (vaginal capsules in four studies and oral capsules in one study; capsules contained single or multiple strains of Lactobacillus species [L. delbrueckii, L. casei, L. rhamnosus, or L. acidophilus], Streptococcus species [S. thermophilum or S. faecalis], and/or Bifidobacterium species [B. breve or B. longum]). Short-term clinical cure was defined as resolution of symptoms plus absence of Candida on microbiologic culture within 14 days. Probiotics significantly improved cure rates (relative risk [RR] = 1.14; 95% CI, 1.05 to 1.24). Three of the RCTs (n = 388) found that adding probiotics to antifungal therapy reduced the relapse rate at one month (RR = 0.34; 95% CI, 0.17 to 0.68) compared with antifungal therapy alone. Relapse was defined

Author disclosure: No relevant financial affiliations.

Address correspondence to Gary Kelsberg, MD, at gkelsberg@gmail.org. Reprints are not available from the authors.


show all references

1. Xie HY, Feng D, Wei DM, et al. Probiotics for vulvovaginal candidiasis in non-pregnant women. Cochrane Database Syst Rev. 2017;(11):CD010496....

2. Russo R, Superti F, Karadja E, et al. Randomised clinical trial in women with recurrent vulvovaginal candidiasis: efficacy of probiotics and lactoferrin as maintenance treatment. Mycoses. 2019;62(4):328–335.

3. Vladareanu R, Mihu D, Mitran M, et al. New evidence on oral L. plantarum P17630 product in women with history of recurrent vulvovaginal candidiasis (RVVC): a randomized double-blind placebo-controlled study. Eur Rev Med Pharm acol Sci. 2018;22(1):262–267.

4. Van Schalkwyk J, Yudin MH; Infectious Disease Committee. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015;37(3):266–274.

5. Mendling W, Brasch J, Cornely OA, et al. Guideline: vulvovaginal candidosis (AWMF 015/072), S2k (excluding chronic mucocutaneous candidosis). Mycoses. 2015;58(suppl 1):1–15.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.



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