What is the best treatment for vaginal candidiasis (vaginal yeast infection)?

Treatment of Vaginal Yeast Infection (Vulvovaginal Candidiasis)

For uncomplicated vulvovaginal candidiasis (VVC), a single 150 mg oral dose of fluconazole or a short course of topical antifungal therapy is recommended as first-line treatment. 1

Diagnosis

Before initiating treatment, confirm the diagnosis of vulvovaginal candidiasis:

• Look for typical symptoms: pruritus, vaginal discharge, vaginal soreness, vulvar burning, dyspareunia, and external dysuria
• Physical examination may reveal vulvar edema, erythema, excoriation, fissures, and white thick curd-like vaginal discharge
• Confirm with wet mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or pseudohyphae
• Check vaginal pH (should be ≤4.5 in VVC)
• If wet mount is negative but symptoms are suggestive, obtain vaginal cultures for Candida

Treatment Algorithm

Uncomplicated VVC (90% of cases)

Defined as mild-to-moderate, sporadic, non-recurrent disease in a normal host with C. albicans

First-line options (equally effective):

1. Oral therapy:

   • Fluconazole 150 mg single oral dose 1, 2

2. Topical therapy options:

   • Butoconazole 2% cream for 3 days
   • Clotrimazole 1% cream for 7-14 days
   • Clotrimazole 100 mg vaginal tablet for 7 days
   • Clotrimazole 100 mg vaginal tablet, two tablets for 3 days
   • Clotrimazole 500 mg vaginal tablet, single application
   • Miconazole 2% cream for 7 days
   • Miconazole 200 mg vaginal suppository for 3 days
   • Miconazole 100 mg vaginal suppository for 7 days
   • Terconazole 0.4% cream for 7 days 3
   • Terconazole 0.8% cream for 3 days
   • Terconazole 80 mg vaginal suppository for 3 days
   • Tioconazole 6.5% ointment, single application 1

Complicated VVC (10% of cases)

Defined as severe or recurrent disease, infection due to non-C. albicans species, and/or VVC in an abnormal host

For severe VVC:

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

For recurrent VVC (≥4 episodes in 12 months):

1. Induction therapy: 10-14 days of topical therapy or oral fluconazole
2. Maintenance therapy: Fluconazole 150 mg once weekly for 6 months 1

For non-C. albicans infections (especially C. glabrata):

• Topical boric acid 600 mg daily for 14 days
• Alternative: Topical 17% flucytosine cream alone or with 3% amphotericin B cream daily for 14 days 1

Efficacy Considerations

• Both oral fluconazole and topical antifungals achieve >90% response rates in uncomplicated VVC 1
• Clinical studies show equivalent efficacy between single-dose oral fluconazole and multi-day topical treatments 4, 5
• Fluconazole provides more rapid symptom relief compared to intravaginal clotrimazole (p<0.001) 5
• Long-term clinical response rates at 27-62 days post-treatment range from 73-88% for fluconazole 6, 7

Patient Preference Considerations

• Oral administration is generally preferred by patients over local therapy 8
• Single-dose oral therapy offers greater convenience compared to multi-day topical treatments

Special Considerations

• Fluconazole is not recommended during pregnancy or lactation 8
• Women with recurrent VVC are less likely to respond to standard treatment (p<0.001) 4
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Women whose symptoms persist after OTC treatment or who experience recurrence within 2 months should seek medical care 1

Follow-up

• For persistent symptoms after treatment, obtain cultures to identify possible resistant organisms
• For recurrent VVC, consider maintenance therapy as outlined above
• Azole-resistant C. albicans infections are extremely rare 1

Remember that after cessation of maintenance therapy for recurrent VVC, a 40-50% recurrence rate can be anticipated 1.