What is the recommended evaluation and treatment for recurrent vulvitis in an adult woman?

Treatment for Recurrent Vulvitis

For recurrent vulvitis (defined as ≥4 episodes per year), initiate a two-phase treatment approach: induction therapy with fluconazole 150 mg on days 1,4, and 7, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months, which achieves symptom control in >90% of patients. 1, 2, 3

Critical First Step: Obtain Vaginal Cultures

Before starting any treatment, you must obtain vaginal cultures to confirm the diagnosis and identify the specific Candida species. 1, 2, 3 This is non-negotiable because:

• 10-20% of recurrent cases are caused by C. glabrata or other non-albicans species that are inherently resistant to fluconazole 1, 2, 3
• Starting empiric fluconazole without culture confirmation may waste months of therapy if the infection is C. glabrata 3
• PCR testing demonstrates superior sensitivity (90.9%) and specificity (94.1%) compared to microscopy alone (sensitivity 57.5%) 2, 3

Treatment Algorithm for Candida albicans (Most Common)

Induction Phase (10-14 days)

Option 1 (Preferred): Fluconazole 150 mg orally on days 1,4, and 7 1, 2, 3

Option 2: Any topical azole therapy for 7-14 days (no single agent is superior to another) 2, 3

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 4
• Miconazole 2% cream 5g intravaginally for 7 days 4
• Terconazole 0.4% cream 5g intravaginally for 7 days 4

Maintenance Phase (6 months)

Primary recommendation: Fluconazole 150 mg orally once weekly for 6 months 1, 2, 3

• Achieves 90.8% disease-free rate at 6 months 3
• Controls symptoms in >90% of patients 1

Alternative maintenance regimens (if fluconazole is contraindicated): 2

• Clotrimazole 500 mg vaginal suppository once weekly
• Itraconazole 400 mg once monthly or 100 mg once daily
• Ketoconazole 100 mg once daily (monitor for hepatotoxicity; 1 in 10,000-15,000 risk) 4, 2

Treatment for Non-Albicans Species (C. glabrata)

Do not use fluconazole for C. glabrata due to intrinsic resistance. 2, 3

First-line treatment: Boric acid 600 mg intravaginal gelatin capsule daily for 14-21 days (achieves 70% eradication rate) 1, 2, 3

Second-line options: 2, 3

• Nystatin 100,000-unit intravaginal suppository daily for 14 days
• Topical 17% flucytosine cream ± 3% amphotericin B cream intravaginally nightly for 14 days

Evaluation for Underlying Conditions

Screen for predisposing factors that may impair treatment response: 2

• Diabetes mellitus: Uncontrolled diabetes significantly impairs treatment response and requires 7-14 days of therapy rather than short courses
• HIV status: HIV-infected women have higher colonization rates correlating with immunosuppression severity (though treatment protocols remain the same) 2, 3
• Immunosuppression: Including corticosteroid use or other debilitating conditions that reduce response to short-term therapies 2
• Pregnancy: Requires topical-only therapy for 7 days; oral fluconazole is contraindicated 2, 3

Special Population Considerations

Pregnant Women

• Use only 7-day topical azole therapy 2, 3
• Oral fluconazole is contraindicated during pregnancy 3
• Clotrimazole, miconazole, butoconazole, and terconazole are the most effective studied agents 4

HIV-Infected Women

• Follow the same diagnostic and therapeutic protocols as HIV-negative women 2, 3
• Response rates are comparable regardless of HIV status 3

Management of Sex Partners

• Routine partner treatment is not recommended as vulvovaginal candidiasis is not typically sexually acquired 4
• Consider partner treatment only in women with persistent recurrences 2
• Treat male partners only if they have symptomatic balanitis (erythematous areas on the glans with pruritus) with topical antifungal agents 4

Critical Pitfalls to Avoid

• Never start empiric fluconazole maintenance without confirming species by culture — you may be treating resistant C. glabrata for months 3
• Never rely on wet mount alone — it may be negative even with active infection 3
• Never use oral fluconazole if the patient becomes pregnant — switch to 7-day topical azole therapy only 3
• Do not discontinue maintenance therapy early — the full 6-month course is necessary to prevent recurrence 1
• Recognize that standard susceptibility testing underestimates resistance — all antifungals have significantly higher MICs at vaginal pH 4 versus pH 7 2, 3
• Avoid self-medication with OTC preparations without proper diagnosis — this can delay identification of other causes of vulvovaginitis 4

Expected Outcomes and Counseling

• Be realistic with patients: After completing 6 months of maintenance fluconazole, 30-50% of women will experience recurrence once therapy is stopped 1, 3
• Women with higher numbers of episodes before treatment, longer duration of disease, or presence of non-albicans species during maintenance are more likely to fail maintenance therapy 2
• Quality of life improves in 96% of women with extended maintenance therapy 3

Follow-Up

• Patients receiving treatment for recurrent vulvovaginal candidiasis should receive regular follow-up to monitor effectiveness of therapy and occurrence of side effects 4
• Instruct patients to return only if symptoms persist or recur within 2 months 4