Recurrent Vulvovaginal Candidiasis

Recurrent vulvovaginal candidiasis is four or more symptomatic episodes of vulvovaginal candidiasis in 12 months, with positive microscopy or culture.

• Most cases are Candida albicans; the rest are non-albicans species such as Candida glabrata, which resist fluconazole.
• Risk factors are diabetes, HIV infection, antibiotics, high-dose oestrogen, steroids and sodium-glucose cotransporter 2 inhibitors.
• Treatment has an induction phase and a maintenance phase.

Vulval itching, soreness, thick white discharge, dyspareunia and dysuria, recurring after symptom-free intervals.

• Vulval erythema, oedema, fissures and satellite lesions.
• Differential diagnosis: bacterial vaginosis, trichomoniasis, contact dermatitis, lichen sclerosus, desquamative inflammatory vaginitis, vulvodynia, psoriasis.
• Complications: chronic vulval pain, secondary dermatitis, sexual dysfunction, psychological distress.

Diagnosis needs confirmation of every episode by microscopy or culture, with a search for risk factors.

• Confirm every episode with microscopy using potassium hydroxide 10 percent, or vaginal swab culture for species identification and fluconazole susceptibility.
• Random blood glucose or HbA1c; HIV test.
• Review drug history: antibiotics, steroids, hormonal contraceptives, sodium-glucose cotransporter 2 inhibitors.
• Vaginal pH (normal, below 4.5, in candidiasis).

Treat with an induction course followed by 6 months of maintenance, and correct risk factors.

• Supportive: avoid soaps, douching, tight synthetic clothing and wet clothes; cotton underwear; control diabetes; weight loss when obese; review contraceptive choice; treat only when symptomatic and confirmed.
• Pharmacological: Candida albicans induction: fluconazole 150 mg oral on days 1, 4 and 7. Maintenance: fluconazole 150 mg oral once weekly for 6 months. Topical alternative: clotrimazole 500 mg pessary intravaginal once weekly for 6 months. Non-albicans (fluconazole-resistant) species: boric acid 600 mg intravaginal capsule nightly for 14 days, or nystatin 100,000 unit pessary intravaginal nightly for 14 days. For symptom relief: clotrimazole 1 percent cream twice daily to the vulva for 7 days.
• Procedures: none.
• Special groups: in pregnancy use topical clotrimazole 100 mg pessary nightly for 7 days and avoid oral fluconazole and boric acid. In diabetes keep HbA1c below 7 percent (53 mmol/mol) and stop sodium-glucose cotransporter 2 inhibitors if possible. In HIV infection start or optimise antiretroviral treatment. In liver impairment avoid prolonged fluconazole, and monitor liver enzymes during 6 months of maintenance.
• Red flags: no response to two treatment courses, ulcers, white plaque, blood-stained discharge, severe immunosuppression.
• Follow-up: review at 3 and 6 months; if recurrence occurs after maintenance stops, repeat the induction and maintenance for a further 6 months.