Treatment for Recurring Vaginal Candidiasis
For recurring vulvovaginal candidiasis (≥4 episodes per year), treat with 10-14 days of induction therapy using either a topical azole or oral fluconazole, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months. 1
Initial Induction Phase (10-14 Days)
- Begin with either topical intravaginal azole therapy daily for 10-14 days OR oral fluconazole 150 mg every 72 hours for 2-3 doses 1
- This induction phase achieves initial control of the recurrent episode before starting suppressive therapy 1
- Confirm diagnosis with wet mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae, and verify normal vaginal pH (4.0-4.5) 1
Maintenance Suppressive Therapy (6 Months)
- Fluconazole 150 mg orally once weekly for 6 months is the most convenient and well-tolerated regimen 1
- This weekly suppressive regimen keeps 90.8% of women disease-free at 6 months 2
- The median time to clinical recurrence with this regimen is 10.2 months compared to 4.0 months with placebo 2
Alternative Maintenance Options
If fluconazole is not feasible:
- Topical clotrimazole 200 mg intravaginally twice weekly 1
- Clotrimazole 500 mg vaginal suppository once weekly 1
- Other intermittent topical azole treatments 1
Critical Management Points
Address predisposing factors such as diabetes mellitus, as controlling these factors is essential before initiating suppressive therapy 1
Expect recurrence after stopping maintenance therapy: 40-50% of patients will experience recurrence after cessation of the 6-month maintenance regimen 1
Special Considerations for Non-Albicans Species
For C. glabrata Infections Unresponsive to Azoles:
- First-line: Topical intravaginal boric acid 600 mg in gelatin capsules daily for 14 days 1
- Second-line: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
- Third-line: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days (requires compounding) 1
Important Clinical Caveats
- Azole-resistant C. albicans infections are extremely rare 1
- Treatment should not differ based on HIV infection status; identical response rates occur in HIV-positive and HIV-negative women 1
- Patients with recurrent vaginitis have significantly lower clinical and mycological response rates compared to those with acute episodes 3
- There is no evidence of fluconazole resistance development in C. albicans isolates or superinfection with C. glabrata during long-term weekly fluconazole therapy 2