What is the treatment for vulva candidiasis?

Treatment of Vulva Candidiasis

For uncomplicated vulvovaginal candidiasis (VVC), 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

Diagnosis Confirmation

Before initiating treatment, diagnosis should be confirmed through:

• Clinical evaluation of symptoms
• Microscopic examination of vaginal secretions with 10% KOH preparation
• Vaginal pH measurement (normal pH ≤4.5 for yeast infections)

Self-diagnosis is unreliable, and microscopic confirmation is required to avoid unnecessary treatments 2.

Treatment Options

First-Line Treatments for Uncomplicated VVC

1. Topical Azole Formulations:

   • Clotrimazole 1% cream: 5g intravaginal application for 7-14 days 1, 3
   • Clotrimazole 2% cream: 5g intravaginal application for 3 days 1
   • Miconazole 2% cream: 5g intravaginal application for 7 days 1
   • Miconazole 4% cream: 5g intravaginal application for 3 days 1
   • Miconazole vaginal suppositories: 100mg daily for 7 days or 200mg daily for 3 days 1
   • Tioconazole 6.5% ointment: 5g intravaginal application as a single dose 1
   • Terconazole 0.4% cream: 5g intravaginal application for 7 days 1
   • Terconazole 0.8% cream: 5g intravaginal application for 3 days 1
   • Butoconazole 2% cream: 5g intravaginal application for 3 days 1

2. Oral Treatment:

   • Fluconazole 150mg as a single oral dose 1, 4

Alternative Treatments

• Nystatin 100,000 units daily for 14 days (topical) 2, 1
• Itraconazole oral solution 200mg twice a day for 1 day or 200mg daily for 3 days 2

Treatment Selection Based on Clinical Presentation

Uncomplicated VVC (90% of cases)

• Short-course therapy (1-7 days) with topical azoles OR
• Single-dose oral fluconazole 150mg
• Clinical cure rates of approximately 80% 1, 4

Complicated VVC (10% of cases)

• Extended treatment course (7-14 days) with topical azoles OR
• Multiple doses of oral fluconazole 1
• Consider maintenance therapy for recurrent cases

Special Considerations

Pregnancy

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

HIV-Infected Patients

• Same treatment as for non-HIV infected patients 1
• May require longer courses for severe cases

Recurrent VVC

• 10-14 days of induction therapy with topical agent or oral fluconazole
• Followed by fluconazole 150mg weekly for 6 months 1
• Alternative: topical intravaginal boric acid, 600mg daily for 14 days 1

Monitoring and Follow-Up

• Response to therapy is typically rapid, with improvement in 48-72 hours 2
• No routine follow-up needed if symptoms resolve completely 1
• Reevaluation necessary if symptoms persist after treatment

Treatment Failure Management

If symptoms persist beyond 7-14 days of appropriate therapy:

1. Confirm diagnosis with culture
2. Consider non-albicans Candida species (particularly C. glabrata and C. krusei) which may be resistant to azoles 1
3. For fluconazole-refractory cases, consider alternative treatments:
   • Extended-course topical therapy
   • Boric acid 600mg daily for 14 days
   • Consultation with specialist for severe or persistent cases

Prevention of Recurrence

• Good genital hygiene
• Wearing cotton underwear
• Avoiding perfumed soaps and bubble baths
• Cleaning from front to back 1

Topical therapy rarely results in adverse effects, though patients might experience cutaneous hypersensitivity reactions. Oral fluconazole may cause gastrointestinal upset and, with prolonged use, potential hepatotoxicity 2, 4.