Management of recurrent acute vulvovaginitis caused by Candida and related species in adults

Recurrent acute vulvovaginitis caused by Candida and related species is defined as 4 or more acute episodes in a year, with at least 2 of these episodes confirmed by microscopy or cultureSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020.

Recurrent episodes of acute vulvovaginitis caused by Candida and related species are thought to be associated with patient-related factors (rather than reintroduction of organisms to the genital tract or infection with more virulent strains); these factors include:

  • immune compromise
  • recent use of antibiotics
  • use of exogenous estrogen (endogenous estrogen can also contribute)
  • diabetes and whether glycaemic targets are achieved.

Enquire about other recurrent infections, especially those suggestive of fungal infection (eg oropharyngeal infection caused by Candida and related species, skin and nail fungal infections); rarely, a history of other recurrent infections may indicate an immune compromise and the need for immunology referralLanternier, 2013Saxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020.

Perform an external examination to exclude alternative or co-existing vulval pathologiesSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020. Take a high vaginal swab for microscopy, culture and sensitivitiesSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020; see Assessment of vulvovaginitis caused by Candida and related species in adults.

If Candida albicans is confirmed on culture for recurrent acute vulvovaginitis in adults, use:

1fluconazole 150 mg orally, on day 1, day 4 and day 7, followed by fluconazole 150 mg orally once a week for 6 monthsRosa, 2013Saxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020. For dosage adjustment in adults with kidney impairment, see fluconazole dosage adjustment fluconazole fluconazole fluconazole

OR

2clotrimazole 1% vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 14 nights, followed by clotrimazole 500 mg pessary intravaginally at bedtime once a week for 6 monthsSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020. clotrimazole clotrimazole clotrimazole

Avoid oral fluconazole in patients who are pregnant or who are trying to conceiveLiu, 2020Zhang, 2019. Single doses of oral fluconazole are safe in breastfeeding, but repeated or high doses should be avoidedSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad, , 2020.

If azole-resistant yeast (eg Nakaseomyces glabratus [formerly known as Candida glabrata]) is confirmed on culture for recurrent acute vulvovaginitis in adults, use:

nystatin 100 000 units/5 g vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 14 nights per month for 6 monthsSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020. nystatin nystatin nystatin

Advise patients on general measures that can help prevent or manage vulvovaginitis; see Treatment of noninfective prepubertal vulvovaginitis.

If there is poor response to therapy for recurrent acute vulvovaginitis caused by Candida and related species, repeat microscopy and culture to assess for microbiological cure or new resistance. In patients who demonstrate microbiological response but no clinical response, reassess for alternative causes of their symptomsSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad, , 2020.