Options for fluconazole-resistant C albicans infection
Patients who have RVVC with frequent and/or prolonged use of fluconazole are at risk for developing azole-resistant isolates of C albicans.12 For patients found to have azole-resistant infections, treatment options include increasing the azole dose based on isolate minimal inhibitory concentrations (MIC) to various antifungals, therapy with a non-fluconazole azole regimen, or switching to a different therapeutic drug class altogether.7
Options for non- albicans Candida species infection
Given the intrinsic resistance to azole therapy in some non-albicans Candida species (specifically C glabrata and Candida krusei), boric acid or nystatin regimens can be used. An induction course of vaginal boric acid is given as 600 mg per vagina daily for up to 14 days and is associated with a 70% rate of mycologic control.7 Boric acid is known to cause local irritation and dermatitis for both the patient and any sexual partners. If ingested orally, boric acid is associated with significant toxicity and even death.7
Vaginal nystatin also may be considered, with an induction course of 100,000 U for 14 days, with a similar regimen recommended for maintenance therapy. However, data are limited on maintenance regimens for RVVC due to non-albicans Candida species.2
Gentian violet
Gentian violet is a topical antiseptic agent that is available over the counter. Use of this agent is uncommon given the availability of highly effective azole-based therapy. Although useful due to its antipruritic properties, gentian violet can be messy to use and tends to stain clothing permanently.
Gentian violet use may be considered in cases of refractory RVVC with or without azole-resistant infections; it is applied as a 1% or 2% solution directly to affected areas for 10 to 14 days.18
Lactobacilli probiotics and dietary changes
Data that support the oral and/or vaginal use of probiotics that contain live lactobacilli are conflicting. In the absence of conclusive evidence to support probiotic use to treat and prevent RVVC, as well as variable quality of available products, use of these agents is not recommended.19
No controlled studies have evaluated the role of various diets in preventing RVVC; thus, no specific dietary changes are recommended.
Behavioral therapy
Available evidence does not support the treatment of sexual partners of patients with RVVC.7
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