What is the recommended treatment for vulvovaginal candidiasis (yeast infections)?

Treatment of Vulvovaginal Candidiasis (Yeast Infections)

For uncomplicated vulvovaginal candidiasis, either topical antifungal agents or a single 150 mg oral dose of fluconazole is recommended as first-line treatment. 1

Classification of Vulvovaginal Candidiasis

Vulvovaginal candidiasis (VVC) can be classified as:

• Uncomplicated (90% of cases):

  • Mild to moderate symptoms
  • Infrequent episodes
  • Likely caused by Candida albicans
  • Occurs in non-immunocompromised patients

• Complicated (10% of cases):

  • Severe symptoms
  • Recurrent episodes (≥4 episodes in 12 months)
  • Caused by non-albicans species (e.g., C. glabrata)
  • Occurs in immunocompromised hosts

Diagnosis

Before initiating treatment, confirm diagnosis through:

• Clinical evaluation of symptoms (pruritus, irritation, vaginal soreness, dysuria, dyspareunia)
• Physical examination (vulvar edema, erythema, white thick discharge)
• Microscopic examination with saline and 10% potassium hydroxide to identify yeast/hyphae
• Vaginal pH measurement (normal pH ≤4.5 for yeast infections)
• Culture for negative microscopy cases or suspected non-albicans species

Treatment Recommendations

Uncomplicated VVC

First-line options (equally effective):

1. Topical antifungal agents 1:

   • 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 vaginal suppositories: 100mg daily for 7 days, 200mg daily for 3 days, or 1200mg single dose
   • Terconazole 0.4% cream: 5g intravaginally daily for 7 days
   • Terconazole 0.8% cream: 5g intravaginally daily for 3 days
   • Terconazole 80mg vaginal suppository: one daily for 3 days
   • Tioconazole 6.5% ointment: 5g intravaginally as single application
   • Butoconazole 2% cream (bioadhesive): 5g intravaginally as single application

2. Oral therapy 1:

   • Fluconazole 150mg as a single oral dose

Severe Acute VVC

• Fluconazole 150mg every 72 hours for a total of 2-3 doses 1

C. glabrata Vulvovaginitis (Unresponsive to Azoles)

1. First option: Topical intravaginal boric acid 600mg daily for 14 days 1
2. Second option: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
3. Third option: Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Recurrent VVC

• 10-14 days induction therapy with topical agent or oral fluconazole
• Followed by maintenance therapy with fluconazole 150mg weekly for 6 months 1, 2

Efficacy and Comparative Data

• Clinical studies show equivalent efficacy between topical agents and oral fluconazole, with cure rates >80% for uncomplicated cases 3, 4
• In a comparative study, single-dose fluconazole (150mg) showed similar efficacy to 7-day clotrimazole treatment, with clinical improvement in 94% vs. 97% of patients at 14 days 4
• For recurrent VVC, maintenance therapy with weekly fluconazole for 6 months significantly reduces recurrence rates (90.8% disease-free at 6 months vs. 35.9% with placebo) 2

Important Considerations

• Confirm diagnosis before treatment to avoid unnecessary medication
• Patients with recurrent VVC are less likely to respond to standard treatment regimens 4
• No evidence supports the superiority of any particular topical agent 1
• Patient preference may influence choice between oral and topical therapy
• Fluconazole should be avoided during pregnancy and lactation 3
• Non-albicans Candida species may be resistant to azoles and require alternative treatments 5
• Persistent symptoms despite treatment may indicate non-albicans species or alternative diagnoses

By following these evidence-based recommendations, most patients with vulvovaginal candidiasis can achieve complete symptom resolution and reduced risk of recurrence.