Stepped Evidence Coverage for Plant-Derived Adjuncts in Vulvovaginal Candidiasis: An Evidence Map and a Proposed Mucosal Antifungal Selectivity Window

In vulvovaginal candidiasis, agents given almost exclusively by the vaginal route yield minimum inhibitory concentrations that cannot be translated into validated susceptibility categories. We asked whether this deficit is interpretive or empirical, and whether it is measurable. Five reproducible searches were run in PubMed, Web of Science, and Scopus, and a plant-derived subset was extracted from the Web of Science corpus by a predefined term filter. After peer review the filter was tested by dual independent screening (kappa 0.96): it had captured 55% of the eligible records, and the corpus was extended to 321 records. All records were coded independently by two reviewers across five domains, with agreement before reconciliation of kappa 0.75 to 1.00 in the original subset and 0.76 to 0.97 in the added records (0.80 to 0.96 across the whole corpus); prevalence uses the 293 primary studies, and a full-text substudy assessed abstract-level coding. Coverage was stepped: quantitative activity (35.8%) and formulation (36.9%) did not differ, both exceeded biofilm (18.1%) and host-cell (14.0%) testing, and all four exceeded commensal testing (4.4%), a gap of 9.6 to 32.5 percentage points (Cochran’s Q p < 0.0001) that the extension widened. Local exposure for topical imidazoles has been quantified in women only in product-registration series of the 1980s and 1990s, varying twentyfold at identical dose. We propose the mucosal antifungal selectivity window, the exposure range in which fungal suppression precedes epithelial injury and commensal disruption, as a hypothesis-generating framework with an operational definition offered for testing; one identified study measured all three domains across overlapping ranges.