What are the current guidelines for diagnosing and managing recurrent vulvovaginal candidiasis in an adult woman who has had four or more symptomatic episodes in the past 12 months?

Management of Recurrent Vulvovaginal Candidiasis

For a woman with recurrent vulvovaginal candidiasis (≥3 episodes per year), obtain vaginal cultures to confirm Candida species before initiating treatment, then start induction therapy with fluconazole 150 mg on days 1,4, and 7, followed by maintenance fluconazole 150 mg weekly for 6 months. 1

Definition and Diagnostic Confirmation

• Recurrent vulvovaginal candidiasis (RVVC) is now defined as three or more symptomatic episodes within 12 months, updated from the previous definition of four or more episodes 2, 1
• Obtain vaginal cultures before starting any treatment to confirm the diagnosis and identify the specific Candida species, as 10-20% of recurrent cases involve non-albicans species (particularly C. glabrata) that are inherently resistant to fluconazole 1, 3
• PCR testing provides superior diagnostic accuracy compared to microscopy alone (sensitivity 90.9% vs 57.5%, specificity 94.1% vs 89.4%) and should be considered when available 2, 3

Treatment Algorithm for Confirmed Candida albicans

Induction Phase (Days 1-7)

• Preferred regimen: Fluconazole 150 mg orally on days 1,4, and 7 1, 3
• Alternative: Any topical azole applied daily for 7-14 days (no single agent has demonstrated superiority over others) 2, 3

Maintenance Phase (6 Months)

• Standard regimen: Fluconazole 150 mg orally once weekly for 6 months, which achieves a 90.8% disease-free rate at 6 months 1, 3, 4
• Alternative maintenance options include clotrimazole 500 mg vaginal suppository weekly, itraconazole 400 mg monthly or 100 mg daily, or ketoconazole 100 mg daily (monitor for hepatotoxicity risk of 1 in 10,000-15,000) 3

Expected Outcomes and Realistic Counseling

• At 6 months: 90.8% disease-free 4
• At 12 months (after stopping maintenance): only 42.9% remain disease-free, meaning 63% of women will experience recurrence after completing the 6-month course 1, 4
• The median time to clinical recurrence after stopping fluconazole is 10.2 months versus 4.0 months with placebo 4

Management of Non-Albicans Species (C. glabrata)

Critical: Do not use fluconazole for C. glabrata infections, as this species has intrinsic resistance and treatment will fail, wasting months of therapy. 1

First-Line Treatment for C. glabrata

• Boric acid 600 mg intravaginal gelatin capsules daily for 14-21 days, achieving a 70% eradication rate 1, 3

Alternative Options for C. glabrata

• Nystatin 100,000-unit suppositories intravaginally daily for 14 days 1, 3
• Compounded topical 17% flucytosine cream ± 3% amphotericin B cream intravaginally nightly for 14 days for refractory infections 1, 3

Special Population Considerations

Pregnancy

• Use only 7-day topical azole therapy (clotrimazole, miconazole, butoconazole, or terconazole) 1, 3
• Oral fluconazole is absolutely contraindicated during pregnancy 1, 3

HIV-Positive Women

• Follow the same diagnostic and therapeutic protocols as HIV-negative women; response rates are comparable regardless of HIV status 1

Uncontrolled Diabetes

• Screen for diabetes mellitus, as uncontrolled diabetes significantly impairs treatment response and requires the full 10-14 day induction course rather than shorter regimens 3, 5

Partner Management

• Routine treatment of male partners is not recommended and does not prevent recurrences, as vulvovaginal candidiasis is not typically sexually transmitted 2, 1, 5
• Consider partner treatment only for men with symptomatic balanitis (erythema and pruritus on the glans); treat with topical antifungal agents 2, 1

Critical Pitfalls to Avoid

• Never start empiric fluconazole maintenance without confirming species by culture, as you may be treating resistant C. glabrata for months without benefit 1
• Never rely on wet mount microscopy alone, as it has poor sensitivity (57.5%) and may be negative even with active infection 2
• Never assume treatment failure means drug resistance first—consider pH effects (all antifungals have significantly reduced activity at vaginal pH 4 versus pH 7 used in laboratory testing) and non-albicans species 1, 3
• Never use oral fluconazole if the patient becomes pregnant; immediately switch to 7-day topical azole therapy only 1
• Avoid patient self-medication with over-the-counter preparations without confirmed diagnosis, as this delays appropriate care and can mask other causes of vulvovaginitis 2, 5

Follow-Up and Monitoring

• Schedule regular follow-up visits at 3,6,9, and 12 months to assess treatment effectiveness and monitor for adverse effects 5
• Instruct patients to return for evaluation if symptoms persist or recur within 2 months of starting therapy 2, 5
• Monitor for fluconazole drug interactions with terfenadine, rifampin, astemizole, phenytoin, cyclosporine, warfarin, or oral hypoglycemics 5

Emerging Therapies

• Oteseconazole (VT-1161) showed promising Phase 2 results with only 4% recurrence at 48 weeks versus 52% with placebo, though Phase 3 data are pending 1
• A vaccine targeting C. albicans has shown efficacy in reducing symptomatic episodes for up to 12 months, but only in women under 40 years of age 1