What is the best course of treatment for a woman of reproductive age experiencing constant vaginal yeast infections?

Treatment of Recurrent Vulvovaginal Candidiasis

For a woman with constant yeast infections, initiate extended-duration therapy (7-14 days of topical azole or fluconazole 150mg repeated after 72 hours) followed by mandatory 6-month maintenance therapy with fluconazole 100-150mg weekly, which achieves symptom control in >90% of patients. 1, 2

Initial Diagnostic Confirmation

Before escalating therapy, confirm the diagnosis is truly recurrent vulvovaginal candidiasis (RVVC), defined as three or more symptomatic episodes over 12 months. 1

• Obtain vaginal cultures to identify the specific Candida species, as 10-20% of RVVC cases involve non-albicans species (particularly C. glabrata) that respond poorly to conventional azole therapy. 1
• Perform microscopy with 10% KOH preparation to visualize yeast or pseudohyphae, and confirm vaginal pH ≤4.5. 2, 3
• Rule out predisposing conditions: uncontrolled diabetes, immunosuppression, recent antibiotic use, or pregnancy. 1, 2

Critical pitfall: Recent research demonstrates that antifungal susceptibility testing at vaginal pH 4 (rather than laboratory standard pH 7) reveals significantly higher MICs, particularly for terconazole against C. glabrata (>388-fold difference), suggesting clinically relevant unrecognized resistance contributing to treatment failure. 1

Two-Phase Treatment Protocol

Phase 1: Induction Therapy (Achieve Mycologic Remission)

For C. albicans infections, use extended-duration initial therapy before starting maintenance:

• Topical azole for 7-14 days: Clotrimazole 1% cream 5g intravaginally daily, miconazole 2% cream, or terconazole 0.4% cream. 1, 2, 3
• OR oral fluconazole: 150mg on day 1, repeated on day 4 (72 hours later). 1, 2

The CDC emphasizes that longer initial therapy is essential to achieve mycologic remission before maintenance—short-duration therapy fails in complicated cases. 1, 2

Phase 2: Maintenance Therapy (6 Months Mandatory)

Once initial remission is achieved, immediately begin maintenance regimen:

• First-line: Fluconazole 100-150mg orally once weekly for 6 months. 1, 2
• Alternative options: Clotrimazole 500mg vaginal suppository once weekly, ketoconazole 100mg daily (requires hepatotoxicity monitoring), or itraconazole 400mg monthly. 1

Quality of life data: Maintenance fluconazole improves quality of life in 96% of women, with median time to recurrence of 10.2 months versus 4.0 months without maintenance. 1, 3

Critical limitation: Despite high success rates during maintenance, 30-40% of women experience recurrence after discontinuing therapy, and recent data shows >63% continue having infections even after completing the full 6-month course. 1

Non-Albicans Species Management

If cultures identify C. glabrata or other non-albicans species:

• First-line: Boric acid 600mg in gelatin capsule intravaginally once daily for 14 days (achieves ~70% clinical and mycologic eradication). 1, 3
• Second-line: Extended non-fluconazole azole therapy for 7-14 days. 1
• Refractory cases: Nystatin 100,000 units vaginal suppository daily as maintenance if non-albicans VVC continues to recur. 1

Partner Treatment Consideration

• Treatment of male sexual partners is not routinely recommended but may be considered in women with recurrent infection. 1, 2
• Treat partners only if they have symptomatic balanitis (erythematous glans with pruritus) using topical antifungal agents. 1
• The CDC notes this approach is controversial, as VVC is not typically sexually acquired. 1

Special Populations

Pregnancy: Use only 7-day topical azole therapy—never oral fluconazole. 1, 2, 3

HIV-infected women: Treat identically to HIV-negative women with the same expected cure rates, though colonization rates are higher and correlate with immunosuppression severity. 1, 2

Emerging Therapies

Oteseconazole, a novel oral CYP51 inhibitor with very long half-life, showed remarkable efficacy in phase 2 trials with only 4% recurrence at 48 weeks versus 52% for placebo when used for 12-24 weeks. 1 Phase 3 data is pending but represents a potentially curative option for this challenging condition.

Common Pitfalls to Avoid

• Never treat based on microscopy alone without symptoms—10-20% of women normally harbor Candida as vaginal flora. 2
• Never use short-duration therapy for RVVC—this guarantees treatment failure. 1, 2
• Never omit the 6-month maintenance phase—induction alone is insufficient. 2, 3
• Never recommend OTC self-treatment for recurrent infections—these require culture-confirmed diagnosis and extended therapy. 1, 2