Treatment of Recurrent Vaginal Yeast Infections
For recurrent vulvovaginal candidiasis, initiate 10-14 days of induction therapy with either topical azole or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months. 1, 2
Diagnostic Confirmation Before Treatment
Before initiating therapy, confirm the diagnosis with:
- Wet mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1, 2
- Verify normal vaginal pH (4.0-4.5) to distinguish from other causes of vaginitis 1, 2
- Obtain vaginal cultures for Candida if wet mount is negative or if patient has failed prior therapy to identify non-albicans species 1
Two-Phase Treatment Protocol
Phase 1: Induction Therapy (10-14 Days)
Choose one of the following regimens:
- Topical intravaginal azole therapy daily for 10-14 days (any azole formulation is acceptable, as no single agent is superior) 1, 2
- Oral fluconazole 150 mg every 72 hours for 2-3 doses 1, 2
The induction phase achieves initial mycologic control before transitioning to suppressive therapy. 2
Phase 2: Maintenance Suppressive Therapy (6 Months)
Fluconazole 150 mg orally once weekly for 6 months is the most convenient and well-tolerated regimen, achieving control of symptoms in >90% of patients. 1, 2, 3 This represents a strong recommendation with high-quality evidence from the Infectious Diseases Society of America. 1
Alternative maintenance regimens (if fluconazole is not feasible):
- Topical clotrimazole 200 mg intravaginally twice weekly 1, 2
- Clotrimazole 500 mg vaginal suppository once weekly 1, 2
- Ketoconazole 100 mg orally daily (requires hepatotoxicity monitoring) 1
A landmark randomized controlled trial demonstrated that weekly fluconazole maintained 90.8% of women disease-free at 6 months compared to 35.9% with placebo (P<0.001), with median time to recurrence of 10.2 months versus 4.0 months. 3
Address Underlying Predisposing Factors
Before initiating suppressive therapy, identify and control contributing factors:
- Uncontrolled diabetes mellitus - optimize glycemic control 1, 2
- Immunosuppression - assess HIV status, corticosteroid use, or other immunocompromising conditions 1
- Antibiotic use - consider timing and frequency of antibiotic exposure 1
Special Considerations for Non-Albicans Species
If cultures reveal C. glabrata or other non-albicans species (found in 10-20% of recurrent cases):
First-line: Topical intravaginal boric acid 600 mg in gelatin capsules daily for 14 days 1, 2 (strong recommendation despite low-quality evidence)
Second-line: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1, 2
Third-line: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days (requires pharmacy compounding) 1, 2
Azole therapy is frequently unsuccessful for C. glabrata infections. 1, 2
Critical Management Expectations
Expect recurrence after stopping maintenance therapy: 40-50% of patients will experience recurrence after cessation of the 6-month maintenance regimen. 1, 2 This is not treatment failure but rather the natural history of recurrent vulvovaginal candidiasis.
Azole-resistant C. albicans infections are extremely rare and should not be a primary concern. 1, 2
Important Clinical Caveats
- Treatment should not differ based on HIV infection status, with identical response rates expected in HIV-positive and HIV-negative women 1, 2
- Patients with recurrent vaginitis (≥4 episodes/year) have significantly lower response rates compared to those with acute vaginitis, regardless of treatment regimen 4, 5
- Self-diagnosis of yeast vaginitis is unreliable, and incorrect diagnosis results in overuse of topical antifungals with subsequent risk of contact and irritant vulvar dermatitis 1
- Fluconazole is well-tolerated with most adverse events being mild gastrointestinal symptoms (nausea, abdominal pain, diarrhea) and headache 4, 3, 6