What are the latest guidelines for treating recurrent vulvovaginitis?

Treatment Guidelines for Recurrent Vulvovaginitis

For recurrent vulvovaginal candidiasis (RVVC), the most effective treatment is a longer 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

Diagnosis and Assessment

• RVVC is defined as four or more episodes of symptomatic vulvovaginal candidiasis within a 12-month period, affecting approximately 5% of women 2, 1
• Vaginal cultures are essential to confirm the clinical diagnosis and identify unusual species, particularly non-albicans species like Candida glabrata 2, 1
• C. glabrata and other non-albicans Candida species are found in 10-20% of RVVC cases and respond differently to conventional treatments 2

Treatment Algorithm for RVVC

Initial Therapy for C. albicans RVVC:

• Longer duration of initial therapy is recommended to achieve mycologic remission before maintenance therapy 2
• Options include:
  • 7-14 days of topical azole therapy OR
  • Oral fluconazole 150 mg with a second dose 72 hours later, followed by a third dose on day 7 2, 1

Maintenance Therapy for C. albicans RVVC:

• After initial therapy, maintenance regimens should be continued for 6 months 2
• Recommended maintenance options include:
  • Fluconazole 100-150 mg orally once weekly 2, 1
  • Clotrimazole 500 mg vaginal suppositories once weekly 2
  • Itraconazole 400 mg once monthly or 100 mg once daily 2

Non-albicans RVVC Treatment:

• Longer duration (7-14 days) of non-fluconazole azole therapy is recommended as first-line treatment 2, 1
• For C. glabrata infections specifically:
  • Boric acid 600 mg in a gelatin capsule vaginally once daily for 14 days (70% eradication rate) 2, 1
  • Alternative: topical 4% flucytosine (may require specialist referral) 2
• For persistent non-albicans RVVC: maintenance regimen of 100,000 units of nystatin delivered daily via vaginal suppositories 2

Special Considerations

Severe VVC:

• For severe vulvovaginitis (extensive erythema, edema, excoriation, fissure formation):
  • Either 7-14 days of topical azole OR
  • Fluconazole 150 mg in two sequential doses (second dose 72 hours after initial dose) 2

Compromised Hosts:

• Women with underlying conditions (uncontrolled diabetes, corticosteroid treatment) require more prolonged (7-14 days) conventional antimycotic treatment 2
• Efforts to correct modifiable conditions should be made 2

Pregnancy:

• Only topical azole therapies, applied for 7 days, are recommended during pregnancy 2

Common Pitfalls to Avoid

• Failure to obtain cultures before initiating treatment for RVVC may miss non-albicans species 2, 1
• Inadequate induction therapy before starting maintenance regimen can lead to persistent infection 1
• Discontinuing maintenance therapy too early (before completing 6 months) can lead to recurrence 2, 1
• Not monitoring for potential drug interactions with oral azoles (including with astemizole, calcium channel antagonists, cisapride, coumadin, cyclosporin A, oral hypoglycemic agents, phenytoin, protease inhibitors) 2
• Self-medication with over-the-counter preparations without proper diagnosis can delay identification of other causes of vulvovaginitis 2, 3

Long-term Management

• After completing the 6-month maintenance regimen, approximately 30-40% of women will experience recurrence once maintenance therapy is discontinued 2, 1
• Surveillance for development of azole resistance is prudent in recurrent cases, although resistance is rare in vaginal C. albicans isolates 2
• Treatment of sex partners is generally not recommended but may be considered in women with recurrent infection 2
• Male partners with balanitis may benefit from topical antifungal treatment 2