What is the treatment for recurrent vaginal yeast infections?

Treatment for Recurrent Vaginal Yeast Infections

For recurrent vulvovaginal candidiasis, the most effective treatment is fluconazole 150 mg weekly for 6 months after initial control of the recurrent episode. 1, 2

Initial Diagnosis and Treatment Approach

• Recurrent vulvovaginal candidiasis (RVVC) is defined as four or more episodes of symptomatic vaginal yeast infection within a 12-month period, affecting approximately 5% of women 1
• Confirm diagnosis with vaginal cultures to identify the causative organism, particularly to detect non-albicans species such as Candida glabrata which may require different treatment 1
• For each acute episode of RVVC caused by C. albicans, use either topical azole therapy for 7-14 days or oral fluconazole 150 mg with a repeat dose 72 hours later to achieve mycologic remission before starting maintenance therapy 1

Maintenance Treatment for Recurrent Infections

For C. albicans Infections:

• Primary recommendation: Fluconazole 150 mg weekly for 6 months after initial control of symptoms 1, 2
• Clinical studies show this regimen keeps 90.8% of women disease-free at 6 months compared to only 35.9% with placebo 2
• Alternative maintenance regimens include:
  • Clotrimazole 500 mg vaginal suppositories once weekly 1
  • Itraconazole 400 mg once monthly or 100 mg daily 1

For Non-albicans Species (particularly C. glabrata):

• For initial treatment: Longer duration (7-14 days) of non-fluconazole azole therapy 1
• If recurrence occurs, use boric acid 600 mg in gelatin capsule vaginally once daily for 14 days (70% eradication rate) 1
• For continued recurrences of non-albicans infections:
  • Nystatin 100,000 units vaginal suppositories daily 1
  • Alternative: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 1

Special Considerations

• Severe vulvovaginitis: (extensive vulvar erythema, edema, excoriation, fissure formation) requires either 7-14 days of topical azole or fluconazole 150 mg given every 72 hours for 2-3 doses 1
• Compromised hosts: (uncontrolled diabetes, corticosteroid treatment) require longer treatment courses (7-14 days) of conventional antifungal therapy 1
• Pregnancy: Only topical azole therapies applied for 7 days are recommended 1
• HIV infection: Higher colonization rates correlate with immunosuppression severity; treatment should follow the same protocols as for non-HIV patients 1

Important Clinical Pearls

• After maintenance therapy is discontinued, 30-40% of women will experience recurrence 1
• Monitor for development of resistance in recurrent isolates, though C. albicans resistance to azoles is rare in vaginal infections 1
• Treatment of sexual partners is generally not recommended for most cases but may be considered for women with recurrent infections 1
• Male partners with balanitis (erythematous areas on glans with pruritus) should receive topical antifungal treatment 1
• Avoid ketoconazole for long-term maintenance due to risk of hepatotoxicity (1 in 10,000-15,000 patients) 1

Treatment Algorithm

1. Confirm diagnosis with wet mount and/or culture
2. Treat acute episode with either:
   • Topical azole for 7-14 days, OR
   • Fluconazole 150 mg orally with repeat dose after 72 hours 1
3. Begin maintenance therapy based on identified species:
   • For C. albicans: Fluconazole 150 mg weekly for 6 months 1, 2
   • For non-albicans species: Follow specific regimens outlined above 1
4. Monitor for recurrence for at least 6 months after completing maintenance therapy 2