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Twice weekly maintenance therapy ideal for recurrent yeast infections

Contemporary OB/GYN Journal, Vol 67 No 7, Volume 67, Issue 7

Vulvovaginal candidiasis (VVC)—commonly known as a yeast infection—is a problem many women face at some point. About half of all women have had at least 1 of these infections clinical diagnosed, and between 6% and 10% are believed to develop a recurrent form of this condition with 3 to 4 or more episodes in a single year, according to a new report.

These infections can cause symptoms like burning, itching, or even pain during and after intercourse. When these infections become chronic or recurrent, the women who experience them usually have to rely on symptomatic control rather than trying to actually resolve the fungal infection.

A new study, published in Women’s Health Reports, sought to develop a consensus among vulvovaginal experts on the best ways to treat chronic or recurrent yeast infections.

For episodic yeast infections, over-the-counter antifungal treatments or a single oral dose of fluconazole are usually used and can resolve symptoms to produce a negative culture in up to 90% of women who complete the regimen.

Recurrent yeast infections, however, are rarely ever “cured.” Curing the fungal infection completely is nearly impossible, and most women with this condition aim instead for mycologic control. This usually takes more than a single course of oral fluconazole—normally 3 doses—or up to 2 weeks of topical treatment. Beyond this initial treatment strategy, however, there is little guidance on what it takes to maintain that control.

The Centers for Disease Control and Prevention (CDC) recommends the use of oral fluconazole weekly for 6 months as an initial first-line treatment for recurrent yeast infections. If oral antifungal medication can’t be used for a number of reasons, the CDC suggests that intermittent topical treatments can be used, but the type and frequency of these treatments isn’t specified.

The study authors note that while most women prefer oral fluconazole over topical medications for convenience, its use may carry additional risk for women:

  • Who take statin medications
  • With kidney disease
  • Who are at risk for arrhythmias
  • Who are pregnant

Additionally, the study reveals that fluconazole may not be effective against infections caused by the nonalbicans species of fungi, which is responsible for up to 20% of recurrent yeast infections. There are some other options for oral treatment, too, including ibrexafungerp. This medication was approved by the U.S. Food and Drug Administration in June 2021 and is taken in just 2 doses given the same day. It kills the fungus instead of just stopping its growth like fluconazole, but is also contraindicated during pregnancy.

Other management strategies for mycologic control in recurrent yeast infections may include things like:

  • Removing implanted devices like IUDs
  • Controlling blood glucose levels and/or diabetes
  • Addressing immunocompromise
  • Reviewing medication use
  • Minimizing the use of corticosteroids and antibiotics

When it comes to topical medication choices, the study concluded that clotrimazole, miconazole, terconazole, and intravaginal boric acid were ideal topical treatments for RVCC caused by Candida albicans. Nystatin ovules are also an option and may actually be more effective, according to CDC, but this medication isn’t commercially available in the United States and must be compounded by a specialty pharmacy.

After initial treatment, the experts polled in the study suggest that topical treatments of whatever medication is used by continued once to 3 times a week, depending on how often symptoms of infection return. In most cases, twice weekly use of topical treatments is sufficient, according to the report. In choosing a topical for maintenance use, the study notes that there is an app available from the International Society for the Vulvovaginal Disease (ISSVD) to help clinicians and patients match the best antifungal with the species of yeast that is causing the problem.

The study authors conclude by stating that while fluconazole may be enough to suppress RVVC in many women, some will need clinician guidance on identifying the cause of their recurrent infection and determining the best course of maintenance treatment.

Reference

  1. Phillips NA, Bachmann G, Haefner H, Martens M, Stockdale C. Topical Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus. Women’s Health Reports. March 2022;3(1):38-42. doi:10.1089/whr.2021.0065.