How do you treat vaginal candida (not glabrata)?

Treatment of Vaginal Candidiasis (Non-glabrata)

For uncomplicated vaginal candidiasis, either a single 150-mg oral dose of fluconazole or a topical antifungal agent for 1-7 days is recommended as first-line therapy, with both options showing equivalent efficacy. 1

Classification and Diagnosis

Before initiating treatment, it's important to properly classify the infection:

• Uncomplicated vulvovaginal candidiasis (90% of cases):

  • First episode or infrequent episodes
  • Mild-to-moderate symptoms
  • Likely caused by Candida albicans
  • Occurs in non-immunocompromised patients

• Complicated vulvovaginal candidiasis (10% of cases):

  • Severe symptoms
  • Recurrent infections (≥4 episodes in 12 months)
  • Non-albicans Candida species
  • Occurs in immunocompromised or diabetic patients

Diagnosis should be confirmed by:

• Wet mount preparation with saline and 10% potassium hydroxide showing yeast or hyphae
• Normal vaginal pH (4.0-4.5)
• Vaginal culture if wet mount is negative but symptoms persist

Treatment Algorithm

1. Uncomplicated Vulvovaginal Candidiasis

Option A: Oral Therapy

• Fluconazole 150 mg single oral dose 1, 2
  • Advantages: Convenient, single dose, systemic coverage
  • Disadvantages: Potential drug interactions, not for use in pregnancy

Option B: Topical Therapy (all equally effective) 1

• Clotrimazole 1% cream 5g intravaginally for 7-14 days, OR
• Clotrimazole 100 mg vaginal tablet for 7 days, OR
• Clotrimazole 500 mg vaginal tablet, single application, OR
• Miconazole 2% cream 5g intravaginally for 7 days, OR
• Miconazole 200 mg vaginal suppository for 3 days, OR
• Miconazole 100 mg vaginal suppository for 7 days, OR
• Other azole products (terconazole, butoconazole, tioconazole)

2. Severe Acute Vulvovaginal Candidiasis

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

3. Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

• Induction phase: 10-14 days of topical therapy or oral fluconazole
• Maintenance phase: Fluconazole 150 mg weekly for 6 months 1, 3
  • This regimen achieves control of symptoms in >90% of patients

Important Clinical Considerations

1. Efficacy: Both oral and topical antifungal formulations achieve equivalent results (>90% response rates in uncomplicated cases) 1, 4

2. Patient Preference: Oral therapy is generally preferred by patients over topical applications 5

3. Side Effects:

   • Fluconazole: Headache (13%), nausea (7%), abdominal pain (6%) 2
   • Topical agents: Local irritation, burning sensation

4. Special Populations:

   • Pregnancy: Topical azoles are preferred; fluconazole is not recommended 5
   • HIV-positive patients: Same treatment approach as HIV-negative patients 1

5. Common Pitfalls:

   • Treating without confirming diagnosis
   • Failing to identify complicated cases that require longer therapy
   • Not addressing recurrent infections with maintenance therapy
   • Using douches or tampons during treatment (may reduce effectiveness) 6
   • Having intercourse during treatment (may reduce effectiveness) 6

Follow-up

• For uncomplicated cases, follow-up is not necessary if symptoms resolve
• For complicated or recurrent cases, follow-up is recommended to ensure resolution
• After cessation of maintenance therapy for recurrent infections, a 40-50% recurrence rate can be anticipated 1

Remember that proper diagnosis is essential before treatment, as symptoms of vulvovaginal candidiasis can mimic other conditions including sexually transmitted infections.