What is the recommended evaluation and management for a woman with recurrent vulvovaginal candidiasis (four or more symptomatic episodes in a 12‑month period)?

Treatment for Recurrent Vaginal Yeast Infections

For recurrent vulvovaginal candidiasis (defined as ≥3-4 episodes per year), obtain vaginal cultures first to identify the Candida species, then treat with induction therapy (fluconazole 150 mg on days 1,4, and 7) followed by maintenance fluconazole 150 mg weekly for 6 months. 1, 2, 3

Confirm the Diagnosis and Identify the Species

Before initiating any treatment, you must obtain vaginal cultures to confirm the diagnosis and identify the specific Candida species. 1, 2, 3 This step is critical because:

• 10-20% of recurrent cases are caused by C. glabrata, which is inherently resistant to fluconazole 2, 4
• Starting empiric fluconazole maintenance without confirming species may waste months of therapy if the patient has C. glabrata 2
• Wet mount microscopy alone is insufficient, as it may be negative even with active infection 2
• PCR testing has higher sensitivity (90.7%) and specificity (93.6%) compared to clinical microscopy (57.5% and 89.4% respectively) 1

Treatment Algorithm for Candida albicans (Most Common)

Induction Phase (First 7-14 Days)

Choose one of the following regimens to achieve initial mycologic remission:

• Fluconazole 150 mg orally on days 1,4, and 7 (preferred) 1, 2
• Alternatively, topical azole therapy for 7-14 days 1, 3

Maintenance Phase (6 Months)

After achieving initial control of symptoms:

• Fluconazole 150 mg orally once weekly for 6 months 1, 2, 3
• This regimen achieves control of symptoms in >90% of patients and a 90.8% disease-free rate at 6 months 1, 2
• Alternative: Clotrimazole 500 mg vaginal suppository once weekly for 6 months 1, 3

Treatment for Non-Albicans Species (C. glabrata)

If cultures identify C. glabrata, do not use fluconazole due to intrinsic resistance. 2, 4 Instead:

• Boric acid 600 mg intravaginal gelatin capsules daily for 14-21 days (achieves 70% eradication rate) 1, 2, 3
• Alternative: Nystatin 100,000-unit suppositories intravaginally daily for 14 days 1, 2
• For refractory cases: Topical 17% flucytosine cream ± 3% amphotericin B cream intravaginally nightly for 14 days 1, 2

These topical formulations must be compounded by a pharmacist for specific patient use. 1

Expected Outcomes and Realistic Counseling

Be realistic with patients about recurrence rates:

• After completing 6 months of maintenance fluconazole, 30-40% of women will experience recurrence once therapy is discontinued 1, 3, 4
• More than 63% of women continue having infections after completing maintenance therapy 2, 4
• Maintenance fluconazole improves quality of life in 96% of women but is uncommonly curative 2, 4

Special Populations

Pregnancy

• Use only 7-day topical azole therapy during pregnancy 1, 2, 3
• Never use oral fluconazole if the patient becomes pregnant 2

HIV-Positive Women

• Treatment should follow the same protocols as for HIV-negative women 1, 3
• Identical response rates are anticipated regardless of HIV status 1

Critical Pitfalls to Avoid

• Never start empiric fluconazole maintenance without confirming species by culture, as you may be treating resistant C. glabrata 2
• Never rely on wet mount alone, as it may be negative even with active infection 2
• Never assume treatment failure means resistance—consider pH effects (all antifungals have significantly reduced activity at vaginal pH 4 versus pH 7) and non-albicans species first 2
• Never use ketoconazole for long-term maintenance due to risk of hepatotoxicity (1 in 10,000-15,000 patients) 3

Partner Treatment

Treatment of sexual partners is generally not recommended for most cases but may be considered for women with recurrent infections. 3 However, male partners with symptomatic balanitis should receive topical antifungal treatment. 3

Emerging Therapies

For women who fail standard maintenance therapy, oteseconazole (VT-1161) showed only 4% recurrence at 48 weeks versus 52% with placebo, though Phase 3 data are pending. 2 A vaccine targeting C. albicans has shown efficacy in reducing symptomatic VVC for up to 12 months, but only in women under 40 years of age. 2