What is the recommended treatment for recurrent vaginal yeast infections?

Treatment for Recurrent Vaginal Yeast Infections

For recurrent vulvovaginal candidiasis (RVVC), the recommended treatment is an initial induction therapy followed by a 6-month maintenance regimen with fluconazole 150 mg weekly, which achieves control of symptoms in >90% of patients. 1

Initial Diagnosis and Assessment

• RVVC is defined as four or more episodes of symptomatic vulvovaginal candidiasis (VVC) within a 12-month period, affecting approximately 5% of women 1
• Vaginal cultures should be obtained to confirm the diagnosis and identify the specific Candida species, particularly to detect non-albicans species like C. glabrata 1
• Non-albicans Candida species are found in 10-20% of RVVC cases and often require different treatment approaches 1

Treatment Algorithm

Step 1: Induction Therapy

• For C. albicans RVVC:
  • Option 1: Fluconazole 150 mg orally, with a second dose 72 hours later, followed by a third dose on day 7 1, 2
  • Option 2: Topical azole therapy for 7-14 days 1
• For non-albicans RVVC:
  • Longer duration (7-14 days) of non-fluconazole azole therapy 1
  • For C. glabrata: Boric acid 600 mg in a gelatin capsule vaginally once daily for 14 days (70% eradication rate) 1

Step 2: Maintenance Therapy (after achieving mycologic remission)

• First-line: Fluconazole 150 mg orally once weekly for 6 months 1, 2
• Alternative options if oral therapy is not feasible:
  • Clotrimazole 500 mg vaginal suppositories once weekly 1, 3
  • Topical azoles 1-3 times weekly 3
  • For non-albicans recurrent infections: Nystatin 100,000 units vaginal suppositories daily 1

Evidence for Effectiveness

• Weekly fluconazole (150 mg) for 6 months has shown 90.8% disease-free rates at 6 months compared to 35.9% with placebo 2
• The median time to recurrence with fluconazole maintenance is 10.2 months versus 4.0 months with placebo 2
• Despite effective maintenance therapy, 30-40% of women will experience recurrence once maintenance therapy is discontinued 1

Special Considerations

Non-albicans Candidiasis

• C. glabrata and other non-albicans species respond poorly to fluconazole 1
• For C. glabrata infections:
  • First-line: Boric acid 600 mg in a gelatin capsule vaginally daily for 14 days 1
  • Alternative: Topical 4% flucytosine (may require specialist referral) 1
  • Nystatin vaginal suppositories have shown effectiveness against fluconazole-resistant strains (64.3% cure rate for C. glabrata) 4

Severe VVC

• For severe vulvovaginitis (extensive vulvar erythema, edema, excoriation, and fissure formation):
  • Extend treatment duration to 7-14 days of topical azole therapy 1
  • Or fluconazole 150 mg orally with a second dose 72 hours after the initial dose 1

Pregnancy

• Only topical azole therapies applied for 7 days are recommended during pregnancy 1
• Fluconazole should be avoided during pregnancy 3

Common Pitfalls to Avoid

• Failure to obtain cultures before initiating treatment for RVVC, which may miss non-albicans species 1
• Inadequate induction therapy before starting maintenance regimen, leading to persistent infection 1
• Discontinuing maintenance therapy too early (should be continued for 6 months) 1
• Not monitoring for potential drug interactions with oral azoles, which may interact with astemizole, calcium channel antagonists, cisapride, coumadin, cyclosporin A, oral hypoglycemic agents, and several other medications 1
• Self-medication with over-the-counter preparations without proper diagnosis, which can delay identification of other causes of vulvovaginitis 1
• Not considering hepatotoxicity risk with long-term ketoconazole use (estimated 1 in 10,000-15,000 persons) 1

Long-term Management

• After completing the 6-month maintenance regimen, approximately 40-50% of women will experience recurrence 1, 2
• For women with multiple relapses, consider individualized decreasing-dose maintenance regimens 5
• Surveillance for development of azole resistance is prudent in recurrent cases, although resistance is rare in vaginal C. albicans isolates 1

Remember that while treatment can effectively control symptoms, a long-term cure for RVVC remains challenging to achieve 2.