• Recurrent vulvovaginal candidiasis is defined (for research purposes) as the occurrence of four or more episodes within a year.
• In decisions about investigation, treatment, and referral, clinical judgement should be used when classifying a woman as having recurrent vulvovaginal candidiasis.

• Eliminate or control predisposing risk factors as far as is practical.
• Take a high vaginal swab for microscopy and speciated culture to confirm the diagnosis, and identify the presence of:
• Non-albicans Candida species.
• A mixed infection such as candidiasis with bacterial vaginosis or trichomoniasis (up to 10% of infections are mixed). See the CKS topics on Bacterial vaginosis and Trichomoniasis.
• Consider alternative diagnoses if a woman has recurrent or persistent symptoms.
• Treat the presenting episode with a longer induction course. Two options are:
• Fluconazole 150 mg every 72 hours for 3 doses, or
• Topical imidazole therapy for 10–14 days according to symptomatic response.
• Seek specialist advice for the treatment of recurrent non-albicans Candida species infections.
• For vulval symptoms, consider using a topical antifungal cream, in addition to the oral or intravaginal antifungal.
• For future management offer:
• Either 'treatment as required' with a prescription to be used if symptoms recur,
• Or a 'maintenance regimen' with 6 months of an oral or intravaginal antifungal (off-licence use).
• Follow up after the maintenance period has been completed.
• If, after completing a course of maintenance therapy, vulvovaginal candidiasis recurs infrequently, treat each episode independently. If recurrent disease is troublesome, repeat the induction and maintenance regimens.
• Choice of antifungal regimen:
• The choice of antifungal and route (oral or intravaginal) will depend upon a number of factors. Most women prefer oral products to intravaginal creams or pessaries, especially for longer-term use.
• For girls between 12 and 16 years old, offer oral fluconazole or itraconazole (off license uses) for induction, maintenance or 'treatment as required'. However, intravaginal antifungals may be considered if the girl is sexually active, if tampons are being used, or if there is no other alternative.

In depth

• Treat the sexual partner only if they are symptomatic.

In depth

• If a similar episode occurs in the future, oral and topical treatments can be bought at pharmacies, and no prescription will be required.
• Over-the-counter products should not be used over the longer term without medical advice.
• To return for assessment by a healthcare professional if the woman:
• Is under 16 or over 60 years of age.
• Is pregnant.
• Has symptoms that are not entirely consistent with a previous episode.
• Has had two episodes in 6 months, and has not consulted a healthcare professional about the condition for more than a year.
• Has had a previous sexually transmitted infection (herself or her partner).
• Has had a previous adverse reaction to an antifungal drug, or antifungal drugs have proved ineffective.

In depth