What is the recommended treatment for vaginal yeast infections?

Treatment of Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, either a single 150-mg oral dose of fluconazole or topical antifungal agents are recommended as first-line treatments, with no one agent being superior to another. 1

First-Line Treatment Options

Oral Treatment

• Fluconazole 150 mg as a single oral dose 1, 2
  • Convenient single-dose regimen
  • Achieves clinical cure rates of 94% at 14 days 2
  • Well-tolerated with minimal side effects

Topical Treatments (7-day regimens)

• Clotrimazole 1% cream 5g intravaginally for 7 days
• Miconazole 2% cream 5g intravaginally for 7 days
• Nystatin 100,000-unit vaginal tablet, one tablet for 14 days

Treatment for Severe Vaginal Yeast Infections

For severe acute Candida vulvovaginitis (extensive vulvar erythema, edema, excoriation, and fissure formation):

• Fluconazole 150 mg every 72 hours for a total of 2-3 doses 1, 3
• Clinical studies show superior cure rates with this regimen compared to single-dose therapy for severe infections 3

Treatment for Recurrent Vulvovaginal Candidiasis

For recurring vulvovaginal candidiasis (defined as ≥4 episodes within 1 year):

1. Initial induction therapy: 10-14 days of topical antifungal or oral fluconazole
2. Maintenance therapy: Fluconazole 150 mg weekly for 6 months 1
3. Alternative maintenance options:
   • Clotrimazole 500-mg vaginal suppositories once weekly 1
   • Ketoconazole 100-mg once daily (monitor for hepatotoxicity) 1

Treatment for Non-albicans Candida Infections

For C. glabrata infections that don't respond to azoles:

1. Boric acid 600 mg in a gelatin capsule, administered vaginally once daily for 14 days 1
2. Alternative options:
   • Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
   • Topical 17% flucytosine cream alone or combined with 3% AmB cream daily for 14 days 1

Special Considerations

Pregnancy

• Only topical azole therapies applied for 7 days are recommended during pregnancy 1
• Avoid oral fluconazole due to potential risks

HIV Infection

• Treatment should not differ from that for seronegative women 1
• Long-term prophylaxis is not routinely recommended in the absence of recurrent infections

Prevention of Recurrence

• Wear cotton underwear
• Avoid tight-fitting clothing
• Avoid irritants like perfumed soaps and bubble baths
• Maintain good genital hygiene, including cleaning from front to back

Treatment Efficacy

Clinical studies demonstrate that single-dose oral fluconazole is as effective as multi-day topical treatments:

• Comparable clinical cure rates between fluconazole and clotrimazole (94% vs. 97% at 14 days) 2
• Fluconazole provides more rapid symptom relief in some studies 4
• Long-term efficacy shows similar therapeutic cure rates between oral and topical options 2, 5, 6

Potential Side Effects

• Fluconazole: Mild gastrointestinal complaints, headache, rare QT prolongation 7
• Topical agents: Local irritation, burning sensation
• Boric acid: Local irritation, do not use if there are open wounds

Remember that treatment should be guided by the severity of infection, history of recurrence, and the specific Candida species involved. For most uncomplicated infections, either the single-dose oral fluconazole or a standard course of topical therapy will be effective.