What is the most effective approach for managing yeast infections in women?

Management of Yeast Infections in Women

For uncomplicated vulvovaginal candidiasis, either a single 150-mg oral dose of fluconazole or topical antifungal agents are equally effective first-line treatments, with cure rates of 80-90%. 1

Diagnosis

Before initiating treatment, confirm the diagnosis with:

• Clinical assessment for symptoms: pruritus, irritation, vaginal soreness, dyspareunia, and white discharge
• Physical examination: vulvar edema, erythema, excoriation, fissures, and thick white discharge
• Laboratory confirmation:
  • Wet mount with saline and 10% KOH to visualize yeast/hyphae
  • Normal vaginal pH (≤4.5)
  • Vaginal cultures if wet mount is negative but symptoms persist

Treatment Algorithm

1. Uncomplicated VVC (90% of cases)

Defined as mild-to-moderate, sporadic, non-recurrent disease in a normal host with C. albicans

Option A: Oral therapy

• Fluconazole 150 mg single oral dose 1
  • Advantages: Convenience, patient preference, systemic coverage
  • Disadvantages: Potential drug interactions, contraindicated in pregnancy

Option B: Topical therapy (all equally effective) 1

• Butoconazole 2% cream for 3 days
• Clotrimazole 1% cream for 7-14 days or vaginal tablets (100 mg for 7 days, 100 mg twice daily for 3 days, or 500 mg single dose)
• Miconazole 2% cream for 7 days or vaginal suppositories (200 mg for 3 days or 100 mg for 7 days)
• Terconazole 0.4% cream for 7 days, 0.8% cream for 3 days, or 80 mg suppository for 3 days
• Tioconazole 6.5% ointment in a single application

2. Complicated VVC (10% of cases)

A. Severe acute VVC

• Fluconazole 150 mg every 72 hours for 2-3 doses 1
• OR extended course (7-14 days) of topical azole therapy 1

B. Recurrent VVC (≥4 episodes in 12 months)

• Initial induction: 10-14 days of topical therapy or oral fluconazole
• Followed by maintenance: Fluconazole 150 mg weekly for 6 months 1
• Alternative maintenance regimens: 1
  • Clotrimazole 500 mg vaginal suppositories weekly
  • Ketoconazole 100 mg daily (monitor for hepatotoxicity)
  • Itraconazole 400 mg monthly or 100 mg daily

C. Non-albicans Candida infections (especially C. glabrata)

For C. glabrata infections unresponsive to azoles: 1

1. Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days
2. Nystatin intravaginal suppositories 100,000 units daily for 14 days
3. Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days

Special Considerations

Pregnancy

• Only topical azole therapies applied for 7 days are recommended 1
• Oral fluconazole is contraindicated 2

HIV Infection

• Treatment should not differ from HIV-negative women 1
• Higher rates of non-albicans species may occur with systemic azole exposure 1

Self-Treatment

• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who have recurrence of the same symptoms 1
• Patients should seek medical care if symptoms persist after OTC treatment or recur within 2 months 1

Common Pitfalls to Avoid

1. Treating without confirming diagnosis: Symptoms of VVC are nonspecific and can be caused by other conditions like bacterial vaginosis or trichomoniasis.

2. Treating asymptomatic colonization: 10-20% of women harbor Candida without symptoms and don't require treatment 1.

3. Inadequate treatment of complicated VVC: Severe or recurrent cases require longer duration therapy or maintenance regimens.

4. Missing non-albicans species: C. glabrata (10-20% of recurrent cases) often requires alternative treatments as it's frequently resistant to azoles 1.

5. Ignoring partner treatment: While routine treatment of sex partners is not recommended for most cases, it may be considered for women with recurrent infections 1.