What are the guidelines for managing recurrent vulvovaginal candidiasis in women?

Management of recurrent vulvovaginal candidiasis (RVVC) in women involves the following clinical steps:

• Initial advice and self-management: Offer information and support resources such as the NHS leaflet on thrush, and reinforce self-management measures to relieve symptoms.
• Risk factor assessment: Reassess for risk factors contributing to persistent or recurrent infection and manage these appropriately.
• Clinical examination and investigations: Arrange an examination of the external genitalia and take a high vaginal swab (HVS) for culture and sensitivity to confirm diagnosis and exclude other or additional conditions.
• Induction and maintenance antifungal treatment: First-line induction therapy is oral fluconazole 150 mg, three doses taken every 72 hours. This is immediately followed by maintenance therapy with oral fluconazole 150 mg once weekly for six months.
• Alternative treatments if fluconazole is contraindicated or not tolerated: Induction with topical imidazole (e.g., clotrimazole 500 mg intravaginal pessary for 7–14 days) and maintenance with either weekly clotrimazole pessary or oral itraconazole 50–100 mg daily for six months. For breastfeeding women, oral antifungals are avoided; intravaginal clotrimazole is preferred.
• Follow-up and management of poor response: Arrange follow-up if there is poor or partial response to maintenance therapy. Check treatment adherence, repeat HVS with full speciation and sensitivity testing, and consider alternative diagnoses if cultures are negative. Specialist advice is recommended if non-albicans Candida species or azole resistance is identified.
• Managing recurrent symptoms between maintenance doses: Consider increasing oral fluconazole to twice weekly or trial of cetirizine 10 mg daily for six months (off-label) especially if allergy history exists.
• Management of future episodes: Treat infrequent recurrences as acute infections. If recurrent disease re-establishes, consider repeating induction and maintenance regimens.
• Partner treatment: Do not routinely treat asymptomatic male sexual partners as vulvovaginal candidiasis is not a sexually transmitted infection.
• Referral criteria: Refer or seek specialist advice if the patient is aged 12–15 years, diagnosis is uncertain, non-albicans or azole-resistant Candida is identified, or if the woman has uncontrolled diabetes with recurrent infection.

Routine use of additional topical imidazole for vulval symptoms in recurrent infection is not recommended due to insufficient evidence.