What is the treatment for recurrent vulvovaginal candidiasis (VVC)?

From the Guidelines

Recurrent vulvovaginal candidiasis is best treated with an initial intensive antifungal regimen followed by maintenance therapy, specifically 10–14 days of induction therapy with a topical agent or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months, as recommended by the Infectious Diseases Society of America 1. This approach is based on high-quality evidence and is aimed at achieving control of acute symptoms and preventing recurrence. The treatment should start with induction therapy to reduce the fungal load, and then maintenance therapy should be initiated to prevent the fungus from reaching levels that cause symptoms.

Some key points to consider in the treatment of recurrent vulvovaginal candidiasis include:

• The use of topical antifungal agents, such as clotrimazole 2% cream or miconazole suppositories, as an alternative to oral fluconazole for induction therapy 1
• The importance of lifestyle modifications, such as wearing cotton underwear, avoiding tight clothing, minimizing sugar intake, and avoiding unnecessary antibiotic use, to reduce the risk of recurrence
• The potential benefit of probiotics containing Lactobacillus species, either orally or vaginally, in preventing recurrence
• The need for culture-directed therapy or evaluation for underlying conditions, such as diabetes or immunosuppression, if symptoms persist despite treatment 1

It is essential to note that the treatment of recurrent vulvovaginal candidiasis should be individualized, and the choice of therapy should be based on the patient's specific needs and circumstances. Additionally, patients should be educated on the importance of adherence to treatment and the need for follow-up to monitor for recurrence.

From the FDA Drug Label

Vaginal candidiasis: Two adequate and well-controlled studies were conducted in the U. S. using the 150 mg tablet. The remaining one-fourth of enrolled patients had recurrent vaginitis (≥4 episodes/12 months) and achieved 57% clinical cure, 47% mycologic eradication, and 40% therapeutic cure

The treatment for recurrent vulvovaginal candidiasis is fluconazole 150 mg PO.

• Clinical cure was achieved in 57% of patients with recurrent vaginitis.
• Mycologic eradication was achieved in 47% of patients with recurrent vaginitis.
• Therapeutic cure was achieved in 40% of patients with recurrent vaginitis 2.

From the Research

Treatment Options for Recurrent Vulvovaginal Candidiasis

• The treatment for recurrent vulvovaginal candidiasis (RVVC) often focuses on symptomatic control rather than mycologic cure 3.
• Current Centers for Disease Control and Prevention (CDC) guidelines recommend oral fluconazole as first-line maintenance, but suggest intermittent topical treatments as an alternative if oral regimens are not feasible 3.

Topical Treatment

• Clotrimazole, miconazole, terconazole, and intravaginal boric acid are suggested recommendations for recurrent vulvovaginitis caused by both Candida albicans and nonalbicans species 3.
• Nystatin ovules may not be as effective as azoles 3.
• Identification of species will influence treatment decisions, and treatment may be modified based on prior response to a specific agent, especially in nonalbicans species 3.

Oral Fluconazole Therapy

• Weekly treatment with fluconazole (150 mg) for six months has been shown to be effective in preventing symptomatic vulvovaginal candidiasis 4, 5.
• A study found that 90.8% of women remained disease-free at 6 months, 73.2% at 9 months, and 42.9% at 12 months with weekly fluconazole treatment, compared to 35.9%, 27.8%, and 21.9% with placebo 4.
• Individualized, degressive, prophylactic maintenance therapy with oral fluconazole has also been shown to be an efficient treatment regimen to prevent clinical relapses in women with RVVC 6.

Other Treatment Options

• Itraconazole has been used to treat acute and recurrent vulvovaginal candidosis, with cure rates of 97.1% and 76.9% in patients with acute and recurrent forms, respectively 7.
• The application of long-term regimens and suppressive therapy with azole drugs may be suggested in patients with recurrent vulvovaginal candidosis 7.