What is the treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

For uncomplicated vulvovaginal candidiasis (VVC), the first-line treatment options include topical azole formulations or a single 150 mg oral dose of fluconazole, both of which are equally effective with clinical cure rates of approximately 80% in acute cases. 1, 2

Diagnosis

• Diagnosis is based on:
  • Symptoms: pruritus, vaginal discharge, soreness, dyspareunia
  • Physical findings: erythema of vagina or vulva, white discharge
  • Laboratory: wet preparation or Gram stain showing yeasts/pseudohyphae
  • Normal vaginal pH (≤4.5)
  • 10% KOH preparation improves visualization of yeast

Treatment Options

Uncomplicated VVC (First Episode or <4 Episodes/Year)

Topical Azole Options:

• Clotrimazole 1% cream: 5g intravaginally for 7-14 days 1
• Clotrimazole 2% cream: 5g intravaginally for 3 days 1
• Miconazole 2% cream: 5g intravaginally for 7 days 1
• Miconazole 4% cream: 5g intravaginally for 3 days 1
• Miconazole 100mg vaginal suppository: One daily for 7 days 1
• Miconazole 200mg vaginal suppository: One daily for 3 days 1
• Miconazole 1200mg vaginal suppository: Single application 1
• Tioconazole 6.5% ointment: 5g intravaginally as single application 1
• Terconazole 0.4% cream: 5g intravaginally for 7 days 1
• Terconazole 0.8% cream: 5g intravaginally for 3 days 1
• Terconazole 80mg suppository: One daily for 3 days 1
• Butoconazole 2% cream: 5g intravaginally for 3 days or single-dose bioadhesive product 1

Oral Option:

• Fluconazole 150mg: Single oral dose 1, 2, 3

Complicated VVC (Severe Symptoms, Non-albicans Species, or Recurrent VVC)

Recurrent VVC (≥4 Episodes/Year):

• Initial treatment: 7-14 days of topical therapy or multiple doses of oral fluconazole 2
• Maintenance therapy: Fluconazole 150mg weekly for 6 months 2

Alternative Treatments for Resistant Cases:

• Boric acid: 600mg intravaginal capsule daily for 14 days 2
• Nystatin: 100,000 units intravaginal suppository daily for 14 days 2

Special Populations

Pregnancy

• Avoid oral fluconazole in first trimester 1
• Topical azoles are preferred throughout pregnancy 2

HIV Infection

• Same treatment as for non-HIV infected patients 1

Treatment Efficacy and Follow-up

• Topical azoles and oral fluconazole have similar efficacy with 80-90% clinical cure rates 1, 4
• No routine follow-up needed if symptoms resolve 2
• Reevaluation necessary if symptoms persist after treatment 2

Common Pitfalls to Avoid

1. Misdiagnosis: Less than half of patients treated for VVC are diagnosed with an objective test 1
2. Self-treatment limitations: Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC experiencing recurrence of the same symptoms 1
3. Persistent symptoms: May indicate non-albicans Candida species requiring alternative treatment 2, 5
4. Overuse of fluconazole: Can lead to development of resistant strains, especially with non-albicans species 5

Treatment Algorithm

1. Assess severity and history:

   • First episode or <4 episodes/year = uncomplicated
   • Severe symptoms, non-albicans species, or ≥4 episodes/year = complicated

2. For uncomplicated VVC:

   • Choose either topical azole (1-7 days) or single-dose oral fluconazole 150mg
   • Patient preference may guide choice (convenience vs. gastrointestinal side effects)

3. For complicated VVC:

   • Extend treatment duration (7-14 days for topical or multiple doses of fluconazole)
   • Consider maintenance therapy for recurrent cases
   • For resistant cases, consider boric acid or nystatin

4. If treatment fails:

   • Confirm diagnosis with culture
   • Consider non-albicans species and adjust treatment accordingly