Treatment of Recurring Vaginitis
For recurring vaginitis, extend initial treatment duration to 7-14 days with topical azoles or oral fluconazole, then implement 6-month maintenance suppression therapy with fluconazole 150 mg weekly to achieve control in over 90% of patients. 1, 2
Initial Diagnostic Approach
Before treating recurrent vaginitis, confirm the specific etiology through:
- Vaginal pH testing: Normal pH ≤4.5 suggests vulvovaginal candidiasis (VVC), while pH >4.5 indicates bacterial vaginosis (BV) or trichomoniasis 3, 1
- Microscopic examination: Use 10% KOH preparation to visualize yeast/pseudohyphae for candidiasis, or saline wet mount to identify clue cells (BV) or motile trichomonads 3, 1
- Culture with speciation: Essential for recurrent cases to identify non-albicans Candida species, which are less responsive to standard azole therapy 2, 4
Treatment Algorithm by Etiology
Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)
Two-phase treatment approach:
Induction Phase:
- Topical azole therapy for 7-14 days (clotrimazole 1% cream 5g intravaginally daily, miconazole 2% cream 5g daily, or terconazole 0.4% cream 5g daily) 3, 1, 2
- Alternative: Fluconazole 150 mg orally every 72 hours for 2-3 doses 2
Maintenance Phase (after achieving remission):
- Fluconazole 150 mg orally once weekly for 6 months achieves symptom control in >90% of patients 1, 2
- Alternative: Clotrimazole 500 mg vaginal suppository once weekly 1
Important caveat: After cessation of maintenance therapy, expect 40-50% recurrence rate, requiring potential reinitiation 2
Non-albicans Candida Species (C. glabrata, C. tropicalis)
- Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days is first-line therapy 2, 5
- These species show reduced susceptibility to standard azoles, making culture identification critical 2, 4
Recurrent Bacterial Vaginosis
Standard treatment:
- Metronidazole 500 mg orally twice daily for 7 days (cure rate 95%) 3
- Alternative: Metronidazole 2g single dose (cure rate 84%) or intravaginal metronidazole gel 0.75% twice daily for 5 days 3
For persistent recurrence:
- Consider maintenance therapy after initial treatment, though specific regimens are less well-established than for VVC 4, 6
- Vaginal products containing Lactobacillus crispatus may have promise for prevention 5
Recurrent Trichomoniasis
- Metronidazole 500 mg orally twice daily for 7 days (preferred over single-dose for recurrent cases) 3, 5
- Critical: Treat all sexual partners simultaneously to prevent reinfection 3, 7
- For treatment failures: Metronidazole 2g daily for 3-5 days 3
Host Factor Evaluation
Automatically classify as complicated vaginitis requiring extended therapy if:
HIV-infected patients receive identical treatment regimens with equivalent response rates 3, 2
Special Considerations for Pregnancy
- Only use topical azole therapy for 7 days—never oral fluconazole due to association with spontaneous abortion and congenital malformations 1, 2
- Metronidazole contraindicated in first trimester for trichomoniasis; can use 2g single dose after first trimester 3
Common Pitfalls to Avoid
- Do not treat asymptomatic colonization: 10-20% of women harbor Candida without infection 3, 2
- Do not use single-dose treatments for recurrent/complicated cases: Reserve for uncomplicated mild-to-moderate disease only 3, 2
- Do not omit maintenance regimen: Initial extended treatment alone has high recurrence rates without suppression 1
- Do not ignore partner treatment for trichomoniasis: This is the only vaginitis requiring partner therapy 3, 7
- Verify therapeutic compliance and rule out reinfection before escalating therapy 1
When Initial Treatment Fails
Reconsider the diagnosis and evaluate for:
- Cytolytic vaginosis (32% of vaginitis cases in recent study, treated with sodium bicarbonate sitz baths) 8
- Desquamative inflammatory vaginitis (treated with topical clindamycin and steroids) 4, 6
- Atrophic vaginitis (treated with topical estrogen) 7, 6
- Mechanical or chemical irritation 3
For confirmed resistant Candida infections: