What is the recommended treatment for recurrent vaginal candidiasis (RVVC)?

Treatment of Recurrent Vulvovaginal Candidiasis

For recurrent vulvovaginal candidiasis (RVVC), defined as ≥4 episodes per year, treat with 10-14 days of induction therapy using either a topical azole or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months as maintenance therapy. 1

Initial Management Approach

Confirm the Diagnosis

• Obtain vaginal cultures to confirm clinical diagnosis and identify the Candida species, particularly to detect non-albicans species like C. glabrata (found in 10-20% of RVVC cases) 1
• C. glabrata does not form pseudohyphae or hyphae and is not easily recognized on microscopy, making culture essential 1
• Most RVVC cases are caused by azole-susceptible C. albicans 1

Induction Phase (Achieve Mycologic Remission)

Duration: 10-14 days 1

Options:

• Topical azole therapy for 10-14 days (any topical agent; no superiority of one over another) 1
• Oral fluconazole 150 mg every 72 hours for 2-3 doses 1
• Alternative: Fluconazole 600 mg during first week (higher induction dose) 2

The longer induction period is critical to achieve mycologic remission before starting maintenance therapy 1

Maintenance Therapy (After Successful Induction)

Primary Recommendation

Fluconazole 150 mg once weekly for 6 months 1

This regimen achieves:

• 90.8% disease-free rate at 6 months 3
• 73.2% disease-free rate at 9 months 3
• 42.9% disease-free rate at 12 months 3
• Median time to recurrence: 10.2 months (vs. 4.0 months with placebo) 3

Alternative Maintenance Regimens

If fluconazole weekly is not feasible 1:

• Clotrimazole 500 mg vaginal suppository once weekly 1
• Itraconazole 400 mg once monthly or 100 mg once daily 1
• Ketoconazole 100 mg once daily (monitor for hepatotoxicity; 1 in 10,000-15,000 risk) 1

All maintenance regimens should continue for 6 months minimum 1

Expected Outcomes and Recurrence

Post-Treatment Expectations

• 30-40% of women will experience recurrence after discontinuing maintenance therapy 1
• Long-term cure remains difficult to achieve despite effective suppression during treatment 3
• No evidence of fluconazole resistance development in C. albicans with this regimen 3

Individualized Degressive Approach (Alternative Strategy)

For patients requiring longer-term management 2:

• Fluconazole 200 mg weekly for 2 months
• Then 200 mg every 2 weeks for 4 months
• Then 200 mg monthly for 6 months
• This achieves 90% disease-free at 6 months and 77% at 12 months 2

Management of Non-Albicans Species

Candida glabrata (Treatment-Resistant)

When unresponsive to oral azoles 1:

1. First-line: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days (70% eradication rate) 1
2. Second-line: Nystatin 100,000 units intravaginal suppository daily for 14 days 1
3. Third-line: Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

These preparations require compounding by a pharmacist 1

Important Clinical Caveats

Partner Treatment

• Not routinely recommended 1
• Consider only in women with persistent recurrences 1
• Treat male partners only if symptomatic balanitis present 1

Poor Prognostic Factors

Women more likely to fail maintenance therapy 2:

• Higher number of episodes before treatment (odds ratio 4.9)
• Longer duration of disease (6.5 vs 3.7 years)
• Presence of Candida non-albicans species during maintenance

Safety Considerations

• Fluconazole is generally well tolerated; most common side effects are headache (13%), nausea (7%), and abdominal pain (6%) 4
• Serious hepatic reactions are rare but monitor in patients with underlying serious conditions 4
• Drug interactions occur with calcium channel blockers, warfarin, oral hypoglycemics, phenytoin, and protease inhibitors 1

Special Populations

• Pregnancy: Use only topical azoles for 7 days; avoid oral fluconazole 1
• HIV-infected women: Treat identically to HIV-negative women 1
• Diabetes/immunosuppression: Optimize underlying condition; may require longer treatment courses 1