Treatment of Vulvovaginal Candidiasis
For uncomplicated vulvovaginal candidiasis, either a single oral dose of fluconazole 150 mg or a short course of topical azole therapy is recommended as first-line treatment, with both approaches achieving >90% response rates. 1
Diagnosis
Before initiating treatment, confirm the diagnosis through:
- Clinical symptoms: pruritus, irritation, vaginal soreness, dyspareunia, and discharge
- Physical examination: vulvar edema, erythema, excoriation, and white curd-like discharge
- Laboratory confirmation: wet-mount preparation with saline and 10% KOH showing yeast/hyphae and normal pH (4.0-4.5)
Treatment Options
Recommended Regimens for Uncomplicated VVC
Oral Option:
- Fluconazole 150 mg as a single dose 1
Topical Options (all equally effective):
Over-the-counter intravaginal agents:
- Clotrimazole 1% cream: 5g intravaginally daily for 7-14 days
- Clotrimazole 2% cream: 5g intravaginally daily for 3 days
- Miconazole 2% cream: 5g intravaginally daily for 7 days
- Miconazole 4% cream: 5g intravaginally daily for 3 days
- Miconazole 100 mg vaginal suppository: One suppository daily for 7 days
- Miconazole 200 mg vaginal suppository: One suppository for 3 days
- Miconazole 1200 mg vaginal suppository: One suppository for 1 day
- Tioconazole 6.5% ointment: 5g intravaginally in a single application
- Clotrimazole 500 mg vaginal tablet: One tablet single application 1
Prescription intravaginal agents:
- Butoconazole 2% cream (single dose bioadhesive product): 5g intravaginally in a single application
- Terconazole 0.4% cream: 5g intravaginally daily for 7 days
- Terconazole 0.8% cream: 5g intravaginally daily for 3 days
- Terconazole 80 mg vaginal suppository: One suppository daily for 3 days 1
Treatment Selection Considerations
- Efficacy: Both oral fluconazole and topical azoles achieve 80-90% cure rates 1
- Convenience: Single-dose oral fluconazole offers better compliance than multi-day topical regimens 2
- Cost: Topical clotrimazole is generally less expensive than oral fluconazole 3
- Pregnancy: Topical azoles are preferred; fluconazole is contraindicated in pregnancy due to potential risk of spontaneous abortion and birth defects 1
Special Situations
Complicated VVC
For severe or complicated infections (severe symptoms, non-albicans species, immunocompromised host, or recurrent VVC):
- Topical therapy for 7-14 days OR
- Fluconazole 150 mg every 72 hours for 3 doses 1
Non-albicans Candida Species
- C. glabrata often doesn't respond to standard azole therapy
- Options include:
- Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days
- Nystatin intravaginal suppositories 100,000 units daily for 14 days
- 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1
Recurrent VVC (≥4 episodes in 12 months)
- Induction therapy: 10-14 days of topical therapy or oral fluconazole
- Maintenance therapy: Fluconazole 150 mg weekly for 6 months 1
Important Considerations
- Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of identical symptoms 1
- Women whose symptoms persist after OTC treatment or who experience recurrence within 2 months should seek medical care 1
- Identifying Candida in asymptomatic women should not lead to treatment, as 10-20% of women normally harbor Candida species in the vagina 1
- Treatment of VVC should not differ based on HIV status; identical response rates are expected for HIV-positive and HIV-negative women 1