What is the best treatment approach for a patient with recurrent (four or more episodes per year) yeast infections, considering potential underlying health conditions such as diabetes or immunosuppression?

Treatment of Recurrent Vulvovaginal Candidiasis

For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat with 10-14 days of induction therapy using either topical azole or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months. 1

Confirm the Diagnosis First

Before initiating treatment, confirm the diagnosis with wet-mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae, with normal vaginal pH (4.0-4.5). 1 If the wet mount is negative but clinical suspicion remains high, obtain vaginal cultures for Candida species identification. 1

Address Underlying Conditions

Evaluate and control contributing factors before starting suppressive therapy, particularly:

• Diabetes mellitus: Optimize glycemic control as uncontrolled diabetes significantly contributes to recurrence 1, 2
• Immunosuppression: Investigate for HIV or other immunodeficiency states in patients with persistent recurrence 3
• Recent antibiotic use: Document as a predisposing factor 4

Induction Phase (10-14 Days)

Choose one of the following regimens to achieve initial control:

Option 1 - Oral fluconazole: 150 mg every 72 hours for 2-3 doses (total 10-14 days) 1, 2

Option 2 - Topical azole: Any intravaginal azole daily for 10-14 days (no single agent is superior) 1

This induction phase achieves >90% initial clinical response and is essential before starting maintenance therapy. 1, 5

Maintenance Suppressive Therapy (6 Months)

Primary regimen: Fluconazole 150 mg orally once weekly for 6 months 1, 2

This regimen achieves symptom control in >90% of patients during the maintenance period. 1, 5 In the landmark randomized controlled trial, 90.8% of women remained disease-free at 6 months with weekly fluconazole versus only 35.9% with placebo (P<0.001). 5

Alternative maintenance regimens (if fluconazole is not feasible):

• Clotrimazole 200 mg intravaginally twice weekly 1, 2
• Clotrimazole 500 mg vaginal suppository once weekly 1

Expected Outcomes and Recurrence

After completing the 6-month maintenance regimen, expect a 40-50% recurrence rate. 1, 2 The median time to clinical recurrence after stopping fluconazole is 10.2 months compared to 4.0 months with placebo. 5 If symptoms recur after completing maintenance therapy, restart the induction and maintenance regimen. 3

Special Considerations for Non-Albicans Species

If cultures reveal C. glabrata (which is often azole-resistant):

First-line: Boric acid 600 mg in gelatin capsules intravaginally daily for 14 days 1, 2

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

Note that voriconazole and other azoles are frequently unsuccessful for C. glabrata vulvovaginitis. 1

Critical Pitfalls to Avoid

• Do not skip the induction phase: Starting directly with weekly fluconazole without initial control leads to treatment failure 1, 2
• Do not assume all recurrent infections are C. albicans: Obtain cultures to identify non-albicans species, particularly C. glabrata, which requires different treatment 1, 3
• Do not treat empirically without confirmation: The symptoms are nonspecific and can result from various infectious and noninfectious etiologies 1
• Azole-resistant C. albicans is extremely rare: If treatment fails despite confirmed C. albicans, consider non-adherence or reinfection before assuming resistance 1, 2

HIV-Specific Considerations

Treatment should not differ based on HIV status, as identical response rates occur in HIV-positive and HIV-negative women. 1, 2 However, optimizing antiretroviral therapy reduces the incidence of recurrent infections in HIV-infected patients. 1