What is the first-line treatment for vulvovaginal candidiasis (fungal vaginosis)?

First-Line Treatment for Vulvovaginal Candidiasis

For uncomplicated vulvovaginal candidiasis (VVC), the first-line treatment is either a single oral dose of fluconazole 150 mg or a short course of topical azole therapy (such as clotrimazole, miconazole, or other azole preparations) for 1-7 days depending on the formulation. 1

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• Symptoms: Pruritus, irritation, vaginal soreness, external dysuria, dyspareunia, and white discharge
• Signs: Vulvar edema, erythema, excoriation, fissures, and thick, white, curd-like discharge
• Laboratory confirmation: Wet-mount preparation with saline and 10% KOH showing yeast or hyphae
• Normal vaginal pH (≤4.5) 1, 2

Treatment Algorithm

Uncomplicated VVC (90% of cases)

• Option 1: Oral therapy

  • Fluconazole 150 mg as a single oral dose 1, 3
  • Achieves >90% response rate 1

• Option 2: Topical therapy (equally effective as oral therapy)

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

Complicated VVC (10% of cases)

Includes severe symptoms, non-albicans species, or abnormal host factors:

• Severe or recurrent disease:

  • Topical azole therapy for 7-14 days, or
  • Fluconazole 150 mg every 72 hours for 3 doses 1

• Non-albicans species (e.g., C. glabrata):

  • Non-fluconazole options as C. glabrata often has reduced susceptibility to azoles
  • Consider boric acid (in gelatin capsules) or nystatin intravaginal suppositories 1

Special Populations

Pregnancy

• Only topical azole therapy should be used
• Oral fluconazole is contraindicated due to risk of spontaneous abortion 1, 2
• Treatment duration of 7 days is recommended 2

HIV-Positive Women

• Same treatment as HIV-negative women
• Identical response rates are anticipated 1

Recurrent Vulvovaginal Candidiasis

For women with ≥4 episodes in 12 months:

1. Induction phase: 10-14 days of topical therapy or oral fluconazole
2. Maintenance phase: Fluconazole 150 mg weekly for 6 months
   • This regimen achieves control of symptoms in >90% of patients
   • After stopping maintenance therapy, 40-50% recurrence rate can be expected 1, 4

Common Pitfalls and Caveats

1. Misdiagnosis: Always confirm diagnosis with microscopy or culture before treatment, as symptoms can mimic other conditions 2

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

3. Inadequate treatment duration: Severe infections may require longer treatment courses 1

4. Partner treatment: Not routinely recommended unless the partner has symptomatic balanitis 1, 2

5. Self-medication: OTC preparations should only be used by women previously diagnosed with VVC who experience recurrence of the same symptoms 1

6. Follow-up: Not necessary if symptoms resolve; patients should return only if symptoms persist or recur 1

7. Drug interactions: Oral azoles may interact with other medications including terfenadine and warfarin 1, 5

By following these evidence-based guidelines, most women with vulvovaginal candidiasis can expect resolution of symptoms and negative cultures in 80-90% of cases after completing appropriate therapy.