What is the dose and frequency of fluconazole (antifungal medication) for recurrent vulvovaginal candidiasis?

Fluconazole Dosing for Recurrent Vulvovaginal Candidiasis

For recurrent vulvovaginal candidiasis (RVVC), the recommended regimen is an induction phase with fluconazole 150 mg every 72 hours for 3 doses, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months. 1, 2

Diagnosis Confirmation

• RVVC is defined as ≥4 episodes of symptomatic infection within one year 3, 1
• Before initiating treatment, confirm diagnosis with:
  • Wet-mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae 3, 1
  • Verification of normal vaginal pH (4.0-4.5) 3, 1
  • Vaginal cultures for Candida if wet mount findings are negative 3

Treatment Protocol

Initial Control (Induction Phase)

• Fluconazole 150 mg orally every 72 hours for a total of 2-3 doses 3, 1, 2
• Alternative: Topical antifungal agent for 10-14 days 3, 1

Maintenance Phase

• After achieving initial control, administer fluconazole 150 mg orally once weekly for 6 months 3, 1, 2
• This regimen achieves control of symptoms in >90% of patients 3, 1, 4
• The median time to clinical recurrence with maintenance therapy is 10.2 months compared to 4.0 months with placebo 4

Special Considerations

Candida Species

• Most RVVC cases (>90%) are caused by C. albicans, which responds well to fluconazole 3, 1
• For C. glabrata infections (fluconazole-resistant):
  • Topical intravaginal boric acid in gelatin capsules, 600 mg daily for 14 days 1, 2
  • Alternative: Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1, 2
  • Another option: Topical 17% flucytosine cream alone or combined with 3% AmB cream daily for 14 days 3, 2

Severity of Infection

• For severe acute vulvovaginal candidiasis, fluconazole 150 mg every 72 hours for 2-3 doses is recommended before starting maintenance therapy 2, 5
• Women with severe symptoms achieve superior clinical and mycologic eradication with a 2-dose fluconazole regimen compared to a single dose 5

Post-Treatment Considerations

• After cessation of the 6-month maintenance therapy, a 40-50% recurrence rate can be anticipated 3, 1
• If symptoms recur after completing the 6-month regimen, consider restarting the maintenance regimen 1
• Long-term weekly treatment with fluconazole has not shown evidence of developing fluconazole resistance in C. albicans isolates 4

Common Pitfalls to Avoid

• Failing to distinguish between uncomplicated and complicated vulvovaginal candidiasis, which require different treatment approaches 2
• Not confirming the diagnosis with appropriate testing before initiating treatment 2
• Inadequate follow-up for patients with recurrent disease 2
• Treating non-albicans Candida species with fluconazole when they may be resistant 3, 2