What is the recommended treatment for recurrent vaginal yeast infections?

Treatment for Recurrent Vaginal Yeast Infections

For recurrent vaginal yeast infections, fluconazole 150 mg weekly for 6 months is the recommended maintenance therapy after initial control of symptoms. 1, 2

Diagnosis and Definition

• Recurrent vulvovaginal candidiasis (RVVC) is defined as ≥4 episodes of symptomatic infection within one year 1
• Before initiating treatment, diagnosis should be confirmed with wet-mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae, and verify normal vaginal pH (4.0-4.5) 1
• For patients with negative wet mount findings, vaginal cultures for Candida should be obtained to identify the causative organism, particularly non-albicans species 1, 2

Initial Treatment Approach

• Initial control of the recurrent episode requires induction therapy with one of the following:
  • Topical antifungal agent for 10-14 days 1
  • Oral fluconazole 150 mg every 72 hours for a total of 2-3 doses 1, 2
• For severe vulvovaginitis, either 7-14 days of topical azole or fluconazole 150 mg given every 72 hours for 2-3 doses is recommended 2
• For C. glabrata infections (which are less responsive to fluconazole), topical intravaginal boric acid (600 mg daily for 14 days) is recommended 1, 2

Maintenance Therapy

• After achieving initial control of symptoms, maintenance therapy with fluconazole 150 mg weekly for 6 months is strongly recommended 1, 2
• This regimen achieves control of symptoms in >90% of patients 1
• Alternative maintenance regimens include clotrimazole 500 mg vaginal suppositories once weekly 2
• Research demonstrates that weekly fluconazole treatment is significantly more effective than placebo in preventing recurrence, with 90.8% of women remaining disease-free at 6 months compared to only 35.9% with placebo 3

Post-Treatment Considerations

• After cessation of the 6-month maintenance therapy, a 40-50% recurrence rate can be anticipated 1, 2
• The median time to clinical recurrence after stopping fluconazole maintenance therapy is approximately 10.2 months 3
• If symptoms recur after completing the 6-month regimen, consider restarting the maintenance regimen 1

Special Considerations

• Most recurrent infections are caused by C. albicans, which responds well to fluconazole 1
• For non-albicans species, particularly C. glabrata, consider:
  • Boric acid 600 mg in gelatin capsule vaginally once daily for 14 days (70% eradication rate) 2
  • Nystatin intravaginal suppositories (100,000 units daily for 14 days) 1
• Women with severe Candida vaginitis achieve superior clinical and mycologic eradication with a 2-dose fluconazole regimen (150 mg given 3 days apart) compared to a single dose 4
• Treatment of sexual partners is generally not recommended for most cases but may be considered for women with recurrent infections 2
• Male partners with balanitis should receive topical antifungal treatment 2

Potential Side Effects

• Fluconazole is generally well-tolerated with primarily mild to moderate side effects 5, 6
• Common side effects include headache (13%), abdominal pain (6%), nausea (7%), and diarrhea (3%) 5
• Avoid ketoconazole for long-term maintenance due to risk of hepatotoxicity (1 in 10,000-15,000 patients) 2

Treatment Challenges

• Patients with a history of recurrent vaginitis are significantly less likely to respond clinically and mycologically to treatment compared to those without such history 6
• Non-albicans Candida infections predict significantly reduced clinical and mycologic response regardless of duration of therapy 4
• No evidence of fluconazole resistance development in C. albicans has been observed during maintenance therapy 3