When There’s No End in Sight: Treating Recurrent Candidiasis

What do you do when a patient has a recurrent yeast infection? This conundrum recently became a discussion on the OBGYN.net forum.

According to the posting clinician, a 30-year-old patient had responded well to fluconazole 200 mg every three days for a month; it was then tapered to every five days. After the patient ran out of medication, the yeast infection recurred. The patient contacted her doctor and said she would like to continue to use the medication for the foreseeable future.

Does this treatment strategy make sense, the treating clinician pondered. How safe is fluconazole, and is it effective in treating recurrent yeast infections?

From the class triazoles class, fluconazole is used to treat such fungal infections as yeast infections. In patients who are likely to develop a yeast infection due to treatment with chemotherapy or radiation therapy, fluconazole is also used to prevent yeast infections.  Although it is considered relatively safe, the US Food and Drug Administration posted an alert in August 2011 that treatment with chronic, high doses (400 mg/day to 800 mg/day) of fluconazole during the first trimester of pregnancy might be associated with rare and distinct birth defects. However, low doses of fluconazole, like the common 150 mg dose used to treat vaginal yeast infections, has not been associated with birth defects.

In a recent study¹ on the use of fluconazole in recurrent candidiasis, researchers found that a personalized treatment regimen was very effective in patients. The study followed patients (average age=29 years old) who completed a short personalized protocol followed by a slowly decreasing administration of fluconazole plus probiotic therapy. After successful completion of this regimen, researchers found approximately 90% had not experienced a recurrence of infection.

The researchers concluded, “The positive results of our study suggest that the 200 mg fluconazole tablet does not necessarily have to be taken for long periods but can be assumed at progressive longer intervals of time in order to develop a kind of ‘gradual hyposensitization’.”

Interestingly, the treatment of recurrent candidiasis may already be taking the form of individualized care. According to another study, just half of respondents noted that they followed current treatment guidelines.²  The researchers further noted that the wide variation in treatment emphasized how difficult it is to treat and manage this condition. “Without good evidence of effective treatments to guide them, clinicians are ‘tailoring’ treatment for patients, possibly based on their own and their patients’ experiences and preferences,” the study authors explained.

Indeed, this notion of differing treatments can be seen in the responses to the original post. One clinician shared positive clinical experience with boric acid 600 mg vaginal suppositories bid for 10 days with prn refills for patients that have problems with recurrences post- fluconazole, ketorolac, and the like. Another clinician recommended application of Gentian Violet to the vagina weekly. Still another reminded the poster reminds that HSV must be ruled out and suggested thickening the vaginal epthileium to make it more resistant trauma, as well as considering treatment for the patient’s partner.

Ultimately, despite the differing opinions, each clinician should leverage the most current research as well as their own experience to help their patients overcome this obstacle.

References

1.  Murina F, Graziottin A, Felice R, et al. The recurrent vulvovaginal candidiasis: proposal of a personalized therapeutic protocol. ISRN Obstet Gynecol. 2011;2011:806065. [Epub].
2.  Watson C, Pirotta M. Recurrent vulvovaginal candidiasis - current management. Aust Fam Physician. 2011 Mar;40(3):149-51.