What is the treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

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

Diagnosis Confirmation

• Diagnosis should be based on:
  • Symptoms (pruritus, vaginal discharge, vulvar burning, dyspareunia)
  • Physical examination findings (erythema of vagina/vulva, white discharge)
  • Normal vaginal pH (≤4.5)
  • Positive microscopic examination with 10% KOH showing yeast or pseudohyphae 2, 1

Treatment Options

Topical Treatments (First-line)

• Clotrimazole options:

  • 1% cream: 5g intravaginally for 7-14 days
  • 2% cream: 5g intravaginally for 3 days
  • 100mg vaginal tablet for 7 days
  • 100mg vaginal tablet, two tablets for 3 days
  • 500mg vaginal tablet, single application

• Miconazole options:

  • 2% cream: 5g intravaginally for 7 days
  • 4% cream: 5g intravaginally for 3 days
  • 100mg vaginal suppository for 7 days
  • 200mg vaginal suppository for 3 days
  • 1200mg vaginal suppository, single application

• Other azoles:

  • Terconazole 0.4% cream: 5g intravaginally for 7 days
  • Terconazole 0.8% cream: 5g intravaginally for 3 days
  • Tioconazole 6.5% ointment: 5g intravaginally as single dose
  • Butoconazole 2% cream: 5g intravaginally for 3 days 2, 1

Oral Treatment (First-line alternative)

• Fluconazole 150mg oral tablet, single dose 1, 3
  • FDA-approved with therapeutic cure rates of 55%, comparable to topical treatments 3
  • Most common side effects: headache (13%), nausea (7%), abdominal pain (6%) 3

Treatment Selection Considerations

1. Efficacy comparison:

   • Topical azoles and oral fluconazole have similar efficacy for uncomplicated cases 1
   • Some studies suggest clotrimazole or itraconazole may be more effective than fluconazole (mycological cure rates: itraconazole 96%, clotrimazole 95%, fluconazole 83%) 4

2. Patient preference factors:

   • Convenience: Single-dose oral treatment vs. multi-day topical application
   • Side effect profile: Topical treatments rarely cause systemic side effects
   • Cost considerations

3. Special populations:

   • Pregnancy: Avoid oral fluconazole in the first trimester; use only topical azoles throughout pregnancy 2, 1
   • HIV infection: Same treatment as non-HIV patients, but may require longer courses for severe cases 1

Management of Treatment Failure

If symptoms persist after initial treatment:

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 confirmed treatment failures, options include:
   • Extended-duration therapy with topical azoles (7-14 days)
   • Alternative antifungals like topical boric acid (600mg daily for 14 days) 1

Recurrent Vulvovaginal Candidiasis (RVVC)

For women with ≥4 episodes in 12 months:

1. Induction therapy: 7-14 days of topical azole or oral fluconazole
2. Maintenance therapy: Fluconazole 150mg weekly for 6 months 1

Important Clinical Pearls

• Response to therapy is typically rapid, with improvement in 48-72 hours 1
• No routine follow-up needed if symptoms resolve 1
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC experiencing recurrence of the same symptoms 1
• Alternative treatments like probiotics may provide additional benefit but should not replace standard antifungal therapy 5
• Good genital hygiene practices help prevent recurrence 1

Treatment Pitfalls to Avoid

• Treating without confirming diagnosis (approximately 10-20% of women normally harbor Candida without symptoms) 2
• Failing to consider non-albicans species in treatment failures
• Using oral fluconazole in pregnancy, especially first trimester 2, 1
• Overlooking potential drug interactions with oral azoles
• Not addressing predisposing factors that may lead to recurrence