Treatment for Recurrent Yeast Infections
For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat with 10-14 days of induction therapy using either topical azole or oral fluconazole 150 mg every 72 hours for 2-3 doses, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months. 1, 2
Diagnosis Confirmation
Before initiating treatment, confirm the diagnosis with: 1, 2
- Wet-mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae
- Vaginal pH testing (should be 4.0-4.5, normal range)
- Vaginal cultures if wet mount is negative but clinical suspicion remains high
Induction Phase (Initial Control)
Choose one of the following regimens to achieve initial disease control: 1, 2
- Topical azole therapy for 10-14 days, OR
- Oral fluconazole 150 mg every 72 hours for a total of 2-3 doses 1, 3
Maintenance Phase (Suppressive Therapy)
After achieving initial control, start fluconazole 150 mg orally once weekly for 6 months. 1, 2, 4
This regimen achieves symptom control in >90% of patients during the maintenance period. 1, 2 However, after stopping the 6-month maintenance therapy, expect a 40-50% recurrence rate. 1, 2
Alternative Maintenance Options
If fluconazole is not feasible, consider: 1
- Topical clotrimazole 200 mg twice weekly, OR
- Clotrimazole 500 mg vaginal suppository once weekly
Special Considerations for Non-Albicans Species
C. glabrata Infections
Most recurrent infections are caused by C. albicans, but C. glabrata requires different management as it is frequently resistant to azoles: 1, 2
First-line for C. glabrata: 1, 2
- Topical intravaginal boric acid 600 mg daily for 14 days (administered in gelatin capsule)
- Nystatin intravaginal suppositories 100,000 units daily for 14 days
- Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days (must be compounded by pharmacy)
C. krusei Infections
C. krusei responds to all topical antifungal agents but is intrinsically resistant to fluconazole. 1
Address Contributing Factors
Before starting maintenance therapy, identify and control predisposing factors: 1
- Diabetes mellitus (optimize glycemic control)
- Immunosuppression
- Antibiotic use
- Hormonal factors
Important Clinical Caveats
Treatment should not differ based on HIV status - identical response rates are expected in HIV-positive and HIV-negative women. 1
Azole-resistant C. albicans infections are extremely rare - if suspected, obtain susceptibility testing before switching to non-azole therapy. 1
Long-term cure remains difficult to achieve - even with optimal 6-month maintenance therapy, nearly half of patients will experience recurrence after stopping treatment. 4 Consider restarting maintenance therapy if symptoms recur. 2
Patients with history of recurrent vaginitis have significantly lower cure rates compared to those without such history, regardless of treatment regimen used. 5, 6