Non-albicans Candida and rare yeasts in vulvovaginal candidiasis: pathogen attribution, antifungal resistance, persistence, and species-informed management.

Vulvovaginal candidiasis (VVC) is usually attributed to Candida albicans (C. albicans), but non-albicans Candida species and rare yeasts are increasingly encountered in recurrent, complicated, or treatment-refractory disease. Their clinical significance is not uniform: some isolates represent causative infection, whereas others reflect colonization, mixed vaginitis, or detection without causality. This Mini Review addresses three linked clinical and biological questions. First, pathogen attribution should move from detection to causative diagnosis. Recurrent or refractory symptoms warrant structured reassessment during an active episode, integrating clinical examination, vaginal pH and microscopy, fungal culture with species-level identification, exclusion of competing diagnoses, and susceptibility testing when indicated. Second, persistence differs from the C. albicans paradigm and may involve niche adaptation, epithelial association, biofilm-associated tolerance, stress survival, and species-dependent relationships between susceptibility phenotypes and persistence-associated traits. Third, management should be species-informed and susceptibility-aware: Nakaseomyces glabratus (formerly Candida glabrata) and Candida krusei/Pichia kudriavzevii require different salvage-treatment logic, whereas evidence for uncommon Candida species and rare yeasts remains limited and case-based. New antifungals have promising activity, but current trials do not establish species-specific efficacy in non-albicans VVC. Probiotics and microbiome-directed interventions should remain investigational adjuncts evaluated in strain-defined, species-stratified trials rather than substitutes for antifungal therapy. We further identify limitations in the evidence base and priorities for vaginally relevant epithelial, immune-cell, and polymicrobial models. Integrating causative attribution with resistance, tolerance, and persistence biology may reduce both undertreatment of clinically attributable infection and overtreatment of colonization or noninfectious vulvovaginal disease.