What is the recommended treatment regimen for recurrent yeast infections?

Recurrent Vulvovaginal Candidiasis Treatment

For recurrent vulvovaginal candidiasis (≥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 once weekly for 6 months as maintenance therapy. 1

Diagnostic Confirmation

• Obtain vaginal cultures before starting treatment to confirm the diagnosis and identify the specific Candida species 1
• This is critical because 10-20% of recurrent cases are caused by non-albicans species like C. glabrata, which require different treatment approaches 1
• Most recurrent cases (approximately 80-90%) are caused by azole-susceptible C. albicans 2, 1

Induction Phase (First 10-14 Days)

Choose one of the following options:

• Topical azole therapy for 10-14 days (any topical agent; no single agent is superior) 1
• Oral fluconazole 150 mg every 72 hours for 2-3 doses 1, 3

The multi-dose fluconazole regimen achieves superior clinical and mycological cure rates compared to single-dose therapy in complicated cases 3, 4

Maintenance Phase (6 Months)

Primary recommendation:

• Fluconazole 150 mg once weekly for 6 months 2, 1

This regimen keeps 90.8% of women disease-free at 6 months and extends median time to recurrence to 10.2 months versus 4.0 months with placebo 5

Alternative maintenance regimens if fluconazole is not feasible:

• 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

Management of Non-Albicans Species

For C. glabrata infections unresponsive to oral azoles:

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

Expected Outcomes and Recurrence

After completing 6 months of weekly fluconazole maintenance therapy 5:

• 90.8% remain disease-free at 6 months
• 73.2% remain disease-free at 9 months
• 42.9% remain disease-free at 12 months
• After stopping maintenance therapy, expect 40-50% recurrence rate 2

Predictors of Treatment Failure

Women more likely to fail maintenance therapy include those with 1:

• Higher numbers of episodes before treatment
• Longer duration of disease
• Presence of Candida non-albicans species during maintenance

Partner Treatment

Partner treatment is not routinely recommended, but may be considered in women with persistent recurrences or when male partners have symptomatic balanitis 1

Safety Considerations

• Fluconazole is generally well tolerated with serious hepatic reactions being rare 1
• No evidence of fluconazole resistance develops in C. albicans isolates with long-term weekly treatment 5
• Drug interactions can occur with certain medications 1
• Azole-resistant C. albicans infections are extremely rare 2, 3