What is the treatment for recurrent vaginal candidiasis (yeast infection)?

Treatment of Recurrent Vaginal Candidiasis

For recurrent vulvovaginal candidiasis (RVVC), the recommended treatment is 10-14 days of induction therapy with a topical agent or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months. 1, 2

Diagnosis and Definition

• RVVC is defined as ≥4 episodes of symptomatic infection within one year 2
• Before starting treatment, confirm diagnosis 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, 2
• For patients with negative wet mount findings, vaginal cultures for Candida should be obtained 1, 2

Treatment Algorithm

Step 1: Initial Control of Acute Episode

• For uncomplicated acute episodes:
  • Single 150 mg oral dose of fluconazole 1, 3
• For severe acute episodes:
  • Fluconazole 150 mg every 72 hours for a total of 2-3 doses 1, 4

Step 2: Maintenance Therapy

• After controlling the acute episode, start maintenance therapy:
  • Fluconazole 150 mg weekly for 6 months 1, 2, 5
  • This regimen achieves control of symptoms in >90% of patients 2, 5

Step 3: Follow-up

• Monitor for symptom recurrence after completion of maintenance therapy 2
• Be aware that after cessation of the 6-month maintenance therapy, a 40-50% recurrence rate can be anticipated 1, 2, 5

Special Considerations for Non-albicans Candida Species

• Most recurrent infections are caused by C. albicans, which responds well to fluconazole 2
• For C. glabrata infections (which are often resistant to azoles):
  • Topical intravaginal boric acid (600 mg daily for 14 days) is recommended 1, 2
  • Alternative: nystatin intravaginal suppositories (100,000 units daily for 14 days) 1, 2
  • Another option: topical 17% flucytosine cream alone or in combination with 3% AmB cream daily for 14 days 1

Evidence Quality and Efficacy

• The recommendation for 6-month maintenance therapy with weekly fluconazole is supported by high-quality evidence and carries a strong recommendation from the Infectious Diseases Society of America 1, 2
• A randomized controlled trial showed that weekly fluconazole maintenance therapy resulted in 90.8% of women remaining disease-free at 6 months compared to only 35.9% with placebo 5
• The median time to recurrence was significantly longer with fluconazole maintenance (10.2 months vs. 4.0 months with placebo) 5

Important Caveats

• Fluconazole resistance in C. albicans is extremely rare in vaginal infections 1
• Patients with a history of recurrent vaginitis are significantly less likely to respond to treatment compared to those without such history 6
• Long-term cure remains difficult to achieve, with many patients experiencing recurrence after maintenance therapy is discontinued 5
• Before starting treatment, rule out other causes of vulvovaginal symptoms as these symptoms are nonspecific 1

Alternative Approaches

• For patients unable to take oral fluconazole, topical clotrimazole (200 mg twice weekly) or clotrimazole (500-mg vaginal suppository once weekly) can be used as maintenance therapy 1
• Some experts have proposed combination approaches using both systemic and topical agents for recurrent cases, though these require further clinical validation 7