A 35-year-old woman with a 10-year history of systemic lupus erythematosus (SLE) on chronic corticosteroids (prednisolone 15 mg daily) presents with recurrent episodes of vulvovaginal candidiasis over the past 6 months. She reports itching, burning, and thick white vaginal discharge. Wet mount microscopy shows budding yeast and pseudohyphae. She has completed three courses of topical clotrimazole cream over 2 months with only temporary relief. What is the most appropriate next step?

Explanation

## Diagnosis: Recurrent Vulvovaginal Candidiasis (RVVC) **Key Point:** Recurrent vulvovaginal candidiasis is defined as ≥4 episodes per year. This patient has had multiple episodes over 6 months despite topical therapy, indicating **recurrent disease** requiring systemic suppressive therapy. **High-Yield:** Risk factors for RVVC in this patient: - Chronic corticosteroid use (impairs cell-mediated immunity) - SLE (autoimmune immunosuppression) - Repeated topical therapy failure (indicates need for systemic approach) ## Management Algorithm for Vulvovaginal Candidiasis ```mermaid flowchart TD A[Vulvovaginal candidiasis diagnosed]:::outcome A --> B{First episode or infrequent?}:::decision B -->|Yes| C[Topical azole cream/suppository<br/>3-7 days]:::action B -->|No| D{Recurrent<br/>≥4 episodes/year?}:::decision D -->|No| E[Repeat topical therapy]:::action D -->|Yes| F[RVVC: Systemic suppression needed]:::outcome F --> G[Fluconazole 150 mg weekly<br/>for 6-12 months]:::action G --> H[Reassess after 6 months]:::decision H -->|Recurrence| I[Extend suppression or<br/>switch to itraconazole]:::action H -->|No recurrence| J[Discontinue suppression]:::action ``` **Clinical Pearl:** The distinction between acute candidiasis and RVVC is critical: - **Acute:** Single or infrequent episodes → topical azoles (clotrimazole, miconazole, fluconazole cream) - **RVVC:** ≥4 episodes/year → systemic suppressive therapy ## Systemic Antifungal Options for RVVC | Agent | Dosing | Duration | Notes | | --- | --- | --- | --- | | **Fluconazole** | 150 mg weekly | 6–12 months | **First-line for RVVC suppression** | | Itraconazole | 200 mg daily or 200 mg BD × 3 days monthly | 6 months | Alternative; less convenient dosing | | Ketoconazole | 200 mg daily | 6 months | Hepatotoxicity risk; rarely used now | **Mnemonic:** **FLUCON** for **RVVC** — **FLUCONazole** is the gold standard for **Recurrent Vulvovaginal CaNdidiasis**. **Warning:** Do not simply repeat topical therapy in RVVC — this patient has already failed three courses. Escalation to systemic therapy is mandatory. **Tip:** Always counsel on: - Predisposing factors (tight clothing, douching, sexual transmission) - Partner evaluation and treatment if symptomatic - Glycemic control (if diabetic) - Reassessment after 6 months of suppression to consider discontinuation [cite:Harrison 21e Ch 196]