What is the treatment for recurrent vaginitis?

Treatment for Recurrent Vaginitis

For recurrent vulvovaginal candidiasis (RVVC), initiate fluconazole 150 mg orally with a second dose 72 hours later followed by a third dose on day 7, then maintain with fluconazole 150 mg weekly for 6 months, which achieves symptom control in over 90% of patients. 1

Initial Diagnostic Workup

Before starting treatment, you must obtain vaginal cultures to confirm the diagnosis and identify the specific pathogen 1, 2:

• For suspected RVVC: Cultures identify non-albicans species (present in 10-20% of cases) that require different treatment approaches 3, 1
• For suspected recurrent bacterial vaginosis (RBV): Cultures confirm the clinical diagnosis and rule out other etiologies 2
• Failure to culture before treatment is a critical pitfall that can lead to treatment failure when non-albicans species are present 1, 2

Treatment Algorithm for Recurrent Vulvovaginal Candidiasis

For C. albicans RVVC (defined as ≥4 episodes per year):

Induction Phase 1:

• Fluconazole 150 mg orally, second dose 72 hours later, third dose on day 7
• Alternative: 7-14 days of topical azole therapy 3, 2

Maintenance Phase (must continue for 6 months) 3, 1:

• Preferred: Fluconazole 150 mg orally once weekly 1
• Alternatives: Clotrimazole 500 mg vaginal suppository weekly, ketoconazole 100 mg daily, or itraconazole 400 mg monthly 3

For Non-albicans RVVC:

• Use 7-14 days of non-fluconazole azole therapy as first-line 3, 1
• Non-albicans species respond poorly to fluconazole 1

For C. glabrata specifically:

• First-line: Boric acid 600 mg in gelatin capsule vaginally once daily for 14 days (achieves 70% eradication) 1
• Alternative: Topical 4% flucytosine (may require specialist referral) 1

Treatment for Recurrent Bacterial Vaginosis

Initial treatment: Oral metronidazole 500 mg twice daily for 10-14 days 4

If initial treatment fails 4:

• Metronidazole vaginal gel 0.75% for 10 days
• Followed by maintenance: twice weekly for 3-6 months

Critical Pitfalls to Avoid

• Inadequate induction therapy: Starting maintenance without proper initial treatment leads to persistent infection 1
• Premature discontinuation: Stopping maintenance before 6 months increases recurrence risk 1
• Missing non-albicans species: Failure to obtain cultures means C. glabrata and other resistant species go undetected 1, 2
• Drug interactions: Oral azoles interact with astemizole, calcium channel antagonists, cisapride, warfarin, cyclosporine, oral hypoglycemics, phenytoin, protease inhibitors, and others 3
• Ketoconazole hepatotoxicity: Monitor liver function if using ketoconazole maintenance (1 in 10,000-15,000 risk) 3

Partner Management

• For RVVC: Partner treatment is generally not recommended as VVC is not sexually transmitted 3, 2
• Consider treating male partners only if they have symptomatic balanitis (erythema and pruritus on glans) with topical antifungals 3
• For RBV: Partner treatment may be considered in women with recurrent infection, though evidence is limited 2

Expected Outcomes and Follow-Up

• After completing 6-month maintenance, 30-40% of women will experience recurrence 3
• At 12-month follow-up, approximately 69% maintain long-term cure 1
• Instruct patients to return only if symptoms persist or recur within 2 months 3
• Surveillance for azole resistance is prudent in recurrent cases, though resistance remains rare 3, 1

Special Considerations

• Severe vulvovaginitis (extensive erythema, edema, excoriation, fissures): Requires 7-14 days of topical azole or fluconazole 150 mg in two sequential doses 72 hours apart 3
• Underlying conditions: Evaluate for diabetes, immunosuppression, and recent antibiotic use that may predispose to recurrence 2
• Self-medication concerns: Over-the-counter preparations should only be used by women with previously confirmed VVC and identical recurrent symptoms 3