What treatment is recommended for a female patient with recurrent thick white clumpy vaginal discharge and itchiness, who was previously treated with Diflucan (fluconazole) last month?

Recurrent Vulvovaginal Candidiasis Treatment

For recurrent vulvovaginal candidiasis (defined as a second episode within one month), you need a longer induction course followed by maintenance suppressive therapy: start with 10-14 days of either topical azole therapy OR fluconazole 150 mg every 72 hours for 3 doses, then continue fluconazole 150 mg once weekly for 6 months. 1, 2

Why This Differs from Your Previous Treatment

Your symptoms one month after single-dose Diflucan treatment indicate recurrent VVC, not uncomplicated VVC, which changes the treatment approach entirely. 1

• Single-dose fluconazole (what you received last month) achieves >90% cure rates only for uncomplicated first episodes 1, 2
• Recurrence within weeks to months classifies you as having complicated/recurrent VVC, requiring the two-phase approach described above 1, 2

The Two-Phase Treatment Protocol

Phase 1: Induction Therapy (10-14 days)

Choose ONE of these equally effective options: 1, 2

• Fluconazole 150 mg every 72 hours for 2-3 doses (total 3 doses over ~6 days) 1
• Topical azole daily for 7-14 days (clotrimazole, miconazole, or other azole creams/suppositories) 1, 2

Phase 2: Maintenance Suppressive Therapy (6 months)

• Fluconazole 150 mg once weekly for 6 months 1, 2, 3
• This maintenance regimen keeps 91% of women symptom-free at 6 months, compared to only 36% without maintenance therapy 3
• After stopping maintenance therapy, median time to recurrence is 10.2 months (versus 4.0 months without maintenance) 3

Critical Diagnostic Step Before Treatment

Do NOT treat empirically again—you need diagnostic confirmation this time: 1, 2

• Get a vaginal wet mount with 10% KOH to confirm yeast/pseudohyphae 1, 2
• Check vaginal pH (should be ≤4.5 for VVC) 1
• Most importantly: obtain vaginal culture with species identification and antifungal susceptibility testing 1, 4

Why Culture Matters in Recurrent Cases

• Women with recurrent VVC have higher rates of non-albicans Candida species (especially C. glabrata) that are often azole-resistant 1, 4
• C. glabrata infections frequently fail azole therapy and require boric acid 600 mg intravaginal capsules daily for 14 days instead 1, 2
• Fluconazole-resistant C. albicans, while rare, does occur in recurrent cases 5

Common Pitfall to Avoid

The biggest mistake is repeating single-dose fluconazole. 1 This approach:

• Works for uncomplicated first episodes but has poor efficacy in recurrent disease 1, 6
• Patients with recurrent vaginitis achieve only 40% therapeutic cure with single-dose therapy versus 59% in those with acute episodes 7, 6
• Without maintenance therapy, up to 50% of women experience recurrence even after successful initial treatment 4, 3

What to Expect

• During maintenance therapy: Over 90% symptom control while on weekly fluconazole 1, 3
• After completing 6 months: 43% remain disease-free at 12 months (versus 22% without maintenance) 3
• Long-term cure remains challenging: Even with optimal therapy, many women eventually experience recurrence, but the maintenance regimen significantly extends disease-free intervals 4, 3

If This Regimen Fails

Consider these possibilities requiring different management: 1, 4

• Non-albicans species (particularly C. glabrata): Switch to boric acid 600 mg intravaginally daily for 14 days 1, 2
• Azole-resistant C. albicans (extremely rare): May require compounded topical flucytosine 17% cream with amphotericin B 3% cream 1
• Misdiagnosis: Symptoms may be from non-Candida causes (bacterial vaginosis, dermatologic conditions, allergic reactions) 1, 4