What is the recommended treatment for recurrent yeast infections?

Treatment for Recurrent Yeast Infections

For recurrent 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 once weekly for 6 months. 1

Definition and Initial Assessment

Recurrent vulvovaginal candidiasis is defined as ≥4 episodes of symptomatic infection within 1 year and is usually caused by azole-susceptible Candida albicans. 1

Before initiating treatment, confirm the diagnosis with:

• Wet mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1, 2
• Vaginal pH measurement (should be 4.0-4.5; elevated pH suggests alternative diagnosis) 1, 2
• Vaginal culture if wet mount is negative but clinical suspicion remains high 1

Treatment Algorithm

Step 1: Address Contributing Factors

Control predisposing conditions such as diabetes before initiating antifungal therapy. 1

Step 2: Induction Phase (10-14 days)

Option A - Oral therapy:

• Fluconazole 150 mg every 72 hours for 2-3 doses 1, 3

Option B - Topical therapy:

• Any topical azole agent for 7-14 days (no single agent is superior) 1

Step 3: Maintenance Phase (6 months)

Primary regimen:

• Fluconazole 150 mg once weekly for 6 months 1, 4
• This achieves control of symptoms in >90% of patients 1
• Keeps 90.8% of women disease-free at 6 months 2, 5

Alternative regimens if fluconazole is not feasible:

• Topical clotrimazole 200 mg twice weekly for 6 months 1
• Clotrimazole 500 mg vaginal suppository once weekly for 6 months 1

Expected Outcomes and Follow-Up

The evidence demonstrates clear efficacy but also important limitations:

• At 6 months: 90.8% remain disease-free with weekly fluconazole 5
• At 9 months: 73.2% remain disease-free 5
• At 12 months: 42.9% remain disease-free 5
• After cessation of maintenance: 40-50% recurrence rate can be anticipated 1

The median time to clinical recurrence after completing 6 months of maintenance therapy is 10.2 months with fluconazole versus 4.0 months with placebo. 5

Special Circumstances

Non-albicans Species (particularly C. glabrata)

If infection is unresponsive to oral azoles and C. glabrata is suspected or confirmed:

First-line:

• Topical intravaginal boric acid 600 mg daily for 14 days (administered in gelatin capsule) 1, 4

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 (must be compounded by pharmacy) 1

Note that therapy with azoles, including voriconazole, is frequently unsuccessful for C. glabrata infections. 1

HIV-Positive Patients

Treatment should not differ based on HIV infection status; identical response rates are anticipated for HIV-positive and HIV-negative women. 1

Important Clinical Considerations

Resistance patterns:

• Azole-resistant C. albicans infections are extremely rare 1
• No evidence of fluconazole resistance development during long-term weekly maintenance therapy 5
• No superinfection with C. glabrata occurs during fluconazole maintenance 5

Safety profile:

• Long-term weekly fluconazole is well-tolerated with minimal adverse effects 5, 3
• Discontinuation due to adverse effects (such as headache) is rare 5

Common Pitfalls to Avoid

• Inadequate induction therapy duration: Using single-dose therapy for recurrent disease leads to treatment failure; always use 10-14 days of induction 1
• Premature discontinuation of maintenance: Stopping before 6 months significantly increases early recurrence risk 1
• Failure to confirm diagnosis: Empiric treatment without microscopy/culture confirmation may miss non-albicans species requiring alternative therapy 1, 2
• Not addressing contributing factors: Uncontrolled diabetes or other predisposing conditions will undermine antifungal efficacy 1