What is the next step in managing a patient with recurrent vaginal candidiasis (three episodes in one year) presenting with cottage cheese discharge?

Management of Recurrent Vulvovaginal Candidiasis

For a patient with three episodes of vaginal candidiasis in one year presenting with cottage cheese discharge, the next step is to initiate a 10-14 day induction therapy with either topical azole or oral fluconazole (150 mg with a repeat dose 72 hours later), followed by maintenance therapy with fluconazole 150 mg weekly for 6 months. 1

Initial Approach

• 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, 2
• Evaluate for predisposing conditions such as diabetes, immunosuppression, or antibiotic use 1
• Three episodes of vulvovaginal candidiasis in one year meets the current definition of recurrent vulvovaginal candidiasis (RVVC) 1

Treatment Algorithm

Step 1: Induction Therapy

• For C. albicans (most common cause):
  • Option A: Topical azole therapy for 7-14 days 1, 2
  • Option B: Oral fluconazole 150 mg with a repeat dose 72 hours later (total of 2 doses) 1, 2
• For non-albicans species (if identified in cultures):
  • Longer duration (7-14 days) of non-fluconazole azole therapy 1, 2
  • For C. glabrata specifically (azole-resistant):
    • Boric acid 600 mg in gelatin capsule vaginally once daily for 14 days 1
    • Alternative: Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
    • Another option: Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Step 2: Maintenance Therapy

• After achieving clinical remission with induction therapy, initiate maintenance therapy:
  • First choice: Fluconazole 150 mg orally once weekly for 6 months 1, 2, 3
  • Alternative options (if fluconazole is not feasible):
    • Clotrimazole 500 mg vaginal suppository once weekly 1, 2
    • Clotrimazole 200 mg twice weekly 1

Expected Outcomes and Follow-up

• Weekly fluconazole maintenance therapy achieves control of symptoms in >90% of patients 1, 3
• After discontinuation of maintenance therapy, 40-50% recurrence rate can be anticipated 1
• No routine follow-up is needed unless symptoms persist or recur 1

Special Considerations

• Treatment of sexual partners is generally not recommended but may be considered for women with recurrent infections 1, 2
• Male partners with balanitis should receive topical antifungal treatment 1, 2
• For pregnant patients, only topical azole therapies applied for 7 days should be used 1, 2
• HIV-positive patients should receive the same treatment as HIV-negative patients 1, 2

Common Pitfalls to Avoid

• Failing to confirm diagnosis with appropriate testing before initiating long-term therapy 1
• Not identifying non-albicans species, which may require alternative treatment approaches 1, 2
• Premature discontinuation of maintenance therapy before completing the full 6-month course 1, 3
• Using ketoconazole for long-term maintenance due to risk of hepatotoxicity (1 in 10,000-15,000 patients) 1, 2
• Not monitoring for development of resistance in recurrent isolates, though C. albicans resistance to azoles is rare in vaginal infections 1, 2

The evidence strongly supports that long-term weekly fluconazole therapy is highly effective in preventing recurrent episodes of vulvovaginal candidiasis, with studies showing disease-free rates of 90.8% at 6 months compared to only 35.9% in placebo groups 3. This approach addresses both the immediate symptoms and provides the best long-term outcome for reducing morbidity and improving quality of life.