Recurrence of vulvovaginal candidiasis is particularly likely if there are predisposing factors, such as antibacterial therapy, pregnancy, diabetes mellitus, or possibly oral contraceptive use (1)
- reservoirs of infection may also lead to recontamination and should be treated; these include other skin sites such as the digits, nail beds, and umbilicus as well as the gastro-intestinal tract and the bladder
- the partner may also be the source of re-infection and, if symptomatic, should be treated with a topical imidazole cream at the same time.
Treatment against candida may need to be extended for 6 months in recurrent vulvovaginal candidiasis.
Some alternative recommended regimens include (1):
- initially, fluconazole by mouth 150 mg every 72 hours for 3 doses, then 150 mg once every week for 6 months;
- initially, intravaginal application of a topical imidazole for 10-14 days, then clotrimazole vaginally 500-mg pessary once every week for 6 months;
- initially, intravaginal application of a topical imidazole for 10-14 days, then itraconazole by mouth 50-100 mg daily for 6 months.
Public Health England guidance states:
If recurrent vaginal candidiasis
- fluconazole (induction/maintenance)
- 150mg every 72 hours for 3 doses THEN 150mg once a week
A systematic review showed that weekly treatment with fluconazole (150 mg) for six months was effective against recurrent vulvovaginal candidiasis (2).
Patients with recurrent vaginal thrush can be advised on self-help measures. These may include:
- if there is any bowel reservoir of organisms then consider treatment with oral antifungals will treat bowel infection
- treatment of male sexual partner (treatment is simultaneous)
- avoid precipitating factors e.g. tight fitting clothes,
- the use of natural yoghurt (taken orally or given intravaginally) - the bacteria in the yoghurt apparently produce pH changes in the vagina that discourage the growth of candida
- diabetes must be excluded
- a large proportion of vulvovaginal candidiasis in diabetes is due to non-albicans Candida species such as C. glabrata (3)
- observational studies indicate that diabetic patients with C. glabrata vulvovaginal candidiasis respond poorly to azole drugs
Reference:
- BNF (June 2021).
- Rosa MI et al. Weekly fluconazole therapy for recurrent vulvovaginal candidiasis: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2013 Apr;167(2):132-6.
- Ray D et al. Prevalence of Candida glabrata and its response to boric acid vaginal suppositories in comparison with oral fluconazole in patients with diabetes and vulvovaginal candidiasis. Diabetes Care. 2007 Feb;30(2):312-7.
- Public Health England (June 2021). Managing common infections: guidance for primary care