What is the treatment for recurrent vaginal candidiasis (yeast infections)?

Treatment for Recurrent Vaginal Yeast Infections

For recurrent vulvovaginal candidiasis, treatment should begin with induction therapy using oral fluconazole or topical azoles for 10-14 days, followed by maintenance therapy with weekly fluconazole 150 mg for at least 6 months.

Definition and Diagnosis

Recurrent vulvovaginal candidiasis (RVVC) is defined as:

• 4 or more symptomatic episodes within a 12-month period
• Affects approximately 5% of women
• Usually caused by azole-susceptible Candida albicans in 80-90% of cases 1

Before starting treatment, vaginal cultures should be obtained to:

• Confirm the clinical diagnosis
• Identify non-albicans species, particularly Candida glabrata, which is found in 10-20% of RVVC cases 1
• Guide appropriate therapy selection

Treatment Algorithm

Step 1: Induction Phase

Choose one of the following options:

Option A: Oral therapy

• Fluconazole 150 mg orally every 72 hours for 3 doses (day 1,4, and 7) 2
• OR fluconazole 100-200 mg daily for 10-14 days 1

Option B: Topical therapy (if fluconazole is contraindicated)

• Clotrimazole 1% cream 5g intravaginally for 7-14 days, OR
• Clotrimazole 100 mg vaginal tablet daily for 7 days, OR
• Other topical azoles for 7-14 days 1

Step 2: Maintenance Phase (after symptom resolution)

• First-line: Fluconazole 150 mg orally once weekly for 6 months 1, 3

  • This regimen achieves control of symptoms in >90% of patients 1
  • Most convenient and well-tolerated option

• Alternative regimens (if fluconazole is not feasible):

  • Clotrimazole 500 mg vaginal suppository once weekly, OR
  • Clotrimazole 200 mg cream twice weekly, OR
  • Other intermittent topical antifungal treatments 1

Special Considerations

Non-albicans Candida Infections

For C. glabrata or other non-albicans species that are often fluconazole-resistant:

1. First-line: Longer duration (7-14 days) of non-fluconazole azole drug 1
2. For recalcitrant cases:
   • Boric acid 600 mg in gelatin capsules vaginally once daily for 14 days (70% eradication rate) 1
   • Topical 17% flucytosine cream alone or with 3% amphotericin B cream 1
   • Nystatin 100,000 units vaginal suppositories daily for maintenance if recurrences continue 1

Severe Vulvovaginitis

For extensive vulvar erythema, edema, excoriation, and fissure formation:

• Either 7-14 days of topical azole OR
• Fluconazole 150 mg in two sequential doses (second dose 72 hours after initial dose) 1

Expected Outcomes and Follow-up

• After successful maintenance therapy, 40-50% recurrence rate can be anticipated once therapy is discontinued 1
• Median time to clinical recurrence after stopping maintenance therapy is approximately 10.2 months versus 4.0 months with placebo 3
• Patients should return for follow-up only if symptoms persist or recur within 2 months of treatment 1

Important Caveats

1. Drug interactions: Oral azoles may interact with multiple medications including astemizole, calcium channel antagonists, cisapride, coumadin, cyclosporin A, oral hypoglycemic agents, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, and rifampin 1

2. Resistance concerns: Azole-resistant C. albicans infections are extremely rare but can develop following prolonged azole exposure 1

3. Partner treatment: Treatment of sex partners is generally not recommended but may be considered in women with recurrent infection. Some male partners may have balanitis and benefit from topical antifungal treatment 1

4. Underlying conditions: Evaluate and address any contributing factors such as uncontrolled diabetes, though these are rarely found in most RVVC cases 1

5. Oil-based products: Creams and suppositories may weaken latex condoms and diaphragms 1