Itraconazole Dosing for Recurrent Vulvovaginal Candidiasis
For recurrent vulvovaginal candidiasis (RVVC), itraconazole should be dosed as either 400 mg once monthly or 100 mg once daily for 6 months as maintenance therapy after achieving initial mycologic remission. 1
Treatment Algorithm
Step 1: Initial Induction Therapy
Before starting maintenance therapy, you must first achieve mycologic remission with longer duration initial treatment (7-14 days of topical azole therapy or fluconazole 150 mg repeated 3 days later). 1, 2 This induction phase is critical—jumping directly to maintenance without clearing the acute infection leads to treatment failure.
Step 2: Maintenance Therapy Options with Itraconazole
The CDC guidelines provide two specific itraconazole regimens for maintenance: 1
- 400 mg once monthly (intermittent dosing)
- 100 mg once daily (continuous dosing)
Both regimens should be continued for 6 months. 1, 2
Important Context on Efficacy
While the CDC guidelines list itraconazole as an option, fluconazole is the first-line maintenance therapy and has demonstrated superior outcomes, improving quality of life in 96% of women. 1 The 2022 CDC review emphasizes that maintenance fluconazole remains the preferred agent for RVVC. 1
Research data on itraconazole shows mixed results:
- Monthly 400 mg itraconazole prophylaxis reduced symptomatic recurrences to 36.4% versus 64.2% in untreated controls during the 6-month treatment period, but this benefit disappeared within months after stopping therapy. 3
- One comparative study found itraconazole 200 mg twice weekly was actually less effective than clotrimazole for suppressive therapy (33.3% failure rate versus 0% with clotrimazole). 4
Critical Caveats
Recurrence after stopping maintenance is common: 30-40% of women will have recurrent disease once any maintenance therapy is discontinued, and one study found over 63% continued to have ongoing infections after completing maintenance. 1 This is not a cure—it's suppression.
Confirm the diagnosis first: Vaginal cultures should be obtained in all RVVC cases to identify non-albicans species (present in 10-20% of RVVC cases), as conventional azole therapies are less effective against these organisms. 1, 2 C. glabrata in particular shows dramatically reduced susceptibility to azoles at normal vaginal pH. 1
Drug interactions matter: Itraconazole has clinically important interactions with calcium channel antagonists, warfarin, cyclosporine, oral hypoglycemics, phenytoin, protease inhibitors, and many other medications. 1 Review the medication list carefully before prescribing.
Monitor for resistance: Although azole resistance is rare in vaginal Candida isolates, surveillance of recurrent isolates for development of resistance is prudent, especially given that antifungal activity is significantly reduced at vaginal pH 4 compared to laboratory testing at pH 7. 1
When Itraconazole May Be Preferred
Consider itraconazole specifically for non-albicans VVC where longer duration (7-14 days) with a non-fluconazole azole drug is recommended as first-line therapy. 1, 2 However, even in this scenario, topical azoles for extended duration may be more appropriate than oral itraconazole.