What is the recommended treatment for a woman with recurrent vulvovaginal candidiasis (≥4 symptomatic episodes in 12 months)?

Treatment of Recurrent Vaginal Yeast Infection

For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat with an intensive 10-14 day induction phase followed immediately by fluconazole 150 mg weekly for 6 months, which achieves a 90.8% disease-free rate at 6 months. 1, 2

Confirm Diagnosis Before Starting Treatment

• Obtain vaginal cultures before initiating any maintenance therapy to confirm the Candida species, because 10-20% of recurrent cases are caused by C. glabrata, which is inherently resistant to fluconazole and will waste months of therapy if treated incorrectly. 3, 1, 4

• Consider PCR testing over wet mount microscopy alone, as PCR demonstrates 90.9% sensitivity versus only 57.5% for microscopy, preventing missed diagnoses. 1, 4

• Verify vaginal pH ≤4.5 to distinguish from bacterial vaginosis, which requires different treatment. 5

Induction Phase (First 10-14 Days)

For confirmed Candida albicans infections:

• Preferred regimen: Fluconazole 150 mg orally on days 1,4, and 7 to achieve mycologic remission before starting maintenance. 1, 4

• Alternative regimen: Any topical azole (clotrimazole, miconazole, or terconazole) applied daily for 7-14 days—no single topical agent has demonstrated superiority over others. 1, 4, 5

Maintenance Phase (6 Months)

• Start fluconazole 150 mg orally once weekly immediately after completing induction, continuing for 6 months without interruption. 3, 1, 4

• This regimen achieves 90.8% disease-free rates at 6 months versus 35.9% with placebo, with median time to recurrence of 10.2 months versus 4.0 months. 2

• Alternative maintenance options if fluconazole is contraindicated: clotrimazole 500 mg vaginal suppository weekly, ketoconazole 100 mg daily (monitor liver enzymes—hepatotoxicity risk 1 in 10,000-15,000), or itraconazole 400 mg monthly. 3, 4

Treatment of Non-Albicans Species

If C. glabrata is identified on culture:

• Do not use fluconazole—it will fail due to intrinsic resistance. 1

• First-line treatment: Boric acid 600 mg intravaginal gelatin capsules daily for 14-21 days, achieving 70% eradication rates. 3, 1, 4

• Second-line options: Nystatin 100,000-unit suppositories daily for 14 days, or compounded topical 17% flucytosine cream ± 3% amphotericin B cream nightly for 14 days. 1, 4

Expected Outcomes and Counseling

• Be realistic with patients: 30-40% of women will experience recurrence once the 6-month maintenance therapy is stopped, and 63% may continue having infections despite completing the full regimen. 3, 1

• Schedule regular follow-up visits during maintenance therapy to monitor effectiveness and adverse effects. 3

Special Populations

Pregnancy:

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

HIV-positive women:

• Follow the same diagnostic and treatment protocols as HIV-negative women—response rates are comparable regardless of HIV status. 3, 1

Partner Management

• Routine treatment of male partners is not recommended because vulvovaginal candidiasis is not sexually transmitted and does not reduce recurrence rates. 3, 4, 5

• Treat male partners only if they have symptomatic balanitis (erythema and pruritus of the glans) with topical antifungal agents. 3, 4

Critical Pitfalls to Avoid

• Never start empiric fluconazole maintenance without confirming species by culture—you may be treating resistant C. glabrata for months without benefit. 1, 4

• Never rely on wet mount alone for diagnosis—it has only 57.5% sensitivity and may be negative even with active infection. 1, 4

• Never treat asymptomatic Candida colonization, which occurs in 10-20% of healthy women and does not require therapy. 3, 5

• Do not advise self-treatment with over-the-counter preparations unless the woman has previously confirmed VVC with identical recurrent symptoms—otherwise, this delays appropriate care. 3, 1, 5

• Recognize that standard laboratory susceptibility testing at pH 7 underestimates resistance, as all antifungals have significantly reduced activity at vaginal pH 4, which explains many "treatment failures." 1

Monitoring During Maintenance Therapy

• Monitor for drug interactions with fluconazole, including calcium channel antagonists, warfarin, oral hypoglycemics, phenytoin, protease inhibitors, and rifampin. 3

• Instruct patients to return for evaluation if symptoms persist or recur within 2 months of starting therapy. 1, 4

• If using ketoconazole for maintenance, monitor liver enzymes due to hepatotoxicity risk. 3, 4