How to prevent recurrent yeast vaginitis

Prevention of Recurrent Yeast Vaginitis

For women with recurrent vulvovaginal candidiasis, a maintenance regimen of fluconazole 150 mg weekly for 6 months after initial control of the infection is the most effective prevention strategy. 1

Initial Diagnosis and Treatment

Before starting preventive therapy, proper diagnosis is essential:

• Confirm diagnosis with wet-mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae
• Check vaginal pH (should be 4.0-4.5 for candidiasis)
• Obtain vaginal cultures to identify Candida species, particularly for recurrent cases
• Rule out non-albicans species (especially C. glabrata), which are found in 10-20% of recurrent cases 1

Initial Control of Acute Episode

Before starting maintenance therapy, achieve mycologic remission with:

• For C. albicans infections:
  • Longer initial therapy: 7-14 days of topical azole therapy OR
  • Fluconazole 150 mg oral dose repeated after 3 days 1
• For severe acute vulvovaginitis:
  • Fluconazole 150 mg every 72 hours for 2-3 doses 1

Maintenance Prevention Regimen

First-line Prevention Strategy

• Fluconazole 150 mg weekly for 6 months 1, 2
  • This regimen has shown 90.8% disease-free rate at 6 months compared to 35.9% with placebo 2
  • Median time to recurrence extends to 10.2 months versus 4.0 months with placebo 2

Alternative Maintenance Regimens

• Clotrimazole 500 mg vaginal suppositories once weekly 1
• Itraconazole 400 mg once monthly or 100 mg daily 1

Special Considerations

For Non-albicans Candida Species

• For C. glabrata unresponsive to oral azoles:
  • Boric acid 600 mg intravaginal capsules daily for 14 days 1
  • Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
  • Topical 17% flucytosine cream alone or with 3% amphotericin B cream for 14 days 1

Lifestyle Modifications

• Maintain good genital hygiene
• Keep the genital area dry
• Wear loose-fitting cotton underwear
• Avoid potential irritants (perfumed soaps, douches) 3

Follow-up

• Most women (30-40%) will experience recurrence once maintenance therapy is discontinued 1
• Patients should return for follow-up only if symptoms persist or recur within 2 months 1
• Consider treatment of male sexual partners if infections are recurrent, though VVC is not usually sexually transmitted 1, 3

Pitfalls to Avoid

1. Misdiagnosis: Always confirm diagnosis with appropriate testing before starting treatment or prevention regimens
2. Inadequate initial treatment: Failure to achieve mycologic remission before starting maintenance therapy
3. Overlooking non-albicans species: These require different treatment approaches
4. Drug interactions: Be aware of potential interactions between fluconazole and other medications including astemizole, calcium channel antagonists, cisapride, coumadin, and others 1
5. Unnecessary treatment of partners: Treatment of sexual partners is not routinely recommended unless the partner has symptoms 1

The evidence strongly supports that long-term weekly fluconazole treatment significantly reduces recurrence rates of symptomatic vulvovaginal candidiasis, though achieving permanent cure remains challenging 2.