What is the management of vaginal candidiasis?

Management of Vaginal Candidiasis

For uncomplicated vaginal candidiasis, treatment with either a single oral dose of fluconazole 150 mg or topical antifungal agents (clotrimazole, miconazole) applied twice daily for 7-14 days is recommended as first-line therapy. 1, 2

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Examination of vaginal discharge characteristics
• Measurement of vaginal pH
• Microscopic examination with saline and 10% potassium hydroxide (KOH) preparations to demonstrate yeast or hyphae 1
• Culture for definitive identification in recurrent or severe cases 1

Treatment Algorithm

Uncomplicated Vaginal Candidiasis

• First-line options (equally effective with 55% therapeutic cure rate) 2:

  • Oral fluconazole 150 mg as a single dose
  • Topical antifungals (clotrimazole, miconazole) applied twice daily for 7-14 days

• Clinical considerations:

  • Oral therapy has more gastrointestinal side effects (16% vs 4% with topical therapy) 2
  • Topical therapy provides faster symptom relief but requires multiple applications
  • Patient preference may guide selection

Severe Vaginal Candidiasis

• Fluconazole 150 mg every 72 hours for 2-3 doses 1
• Consider combination therapy with oral fluconazole plus topical antifungal 1

Non-albicans Candida Infections (e.g., C. glabrata)

• Topical intravaginal boric acid, 600 mg daily for 14 days 1
• Alternative: nystatin intravaginal suppositories, 100,000 units daily for 14 days 1

Recurrent Vaginal Candidiasis (≥4 episodes/12 months)

• Initial intensive treatment with fluconazole 150 mg every 72 hours for 3 doses 1
• Followed by maintenance therapy with weekly fluconazole 150 mg for 6 months 3
• For fluconazole-resistant cases: consider itraconazole 200 mg daily for 7 days 1

Treatment Efficacy and Considerations

• Clinical cure rates for single-dose fluconazole vs. topical antifungals are comparable (69% vs. 72%) 2
• Mycologic eradication rates are also similar (61% vs. 60%) 2
• Patients with acute vaginitis (<4 episodes/12 months) achieve better outcomes (80% clinical cure) than those with recurrent vaginitis (57% clinical cure) 2

Important Precautions

• Do not use tampons during treatment as they may remove medication from the vagina 4
• Avoid vaginal intercourse during treatment 4
• Do not use other vaginal products (douches, spermicides) during treatment as they may interfere with effectiveness 4
• Condoms and diaphragms may be damaged by topical antifungal products 4

Prevention of Recurrence

• Keep genital area cool and dry
• Wear cotton underwear and loose-fitting clothes
• Change out of damp clothes promptly
• Consider evaluation for underlying conditions such as:
  • Diabetes
  • Immunosuppression
  • Recent antibiotic use
  • Hormonal changes 4

Follow-up

• Reassessment within 1-2 weeks is recommended to ensure resolution of symptoms 1
• Consider alternative diagnosis if no improvement after 72 hours of appropriate therapy 1
• For recurrent cases, identify and address potential sources of reinfection (oral cavity, intestine, sexual partner) 5

Common Pitfalls

1. Failure to identify non-albicans Candida species, which may be resistant to standard azole therapy
2. Not addressing underlying predisposing factors (diabetes, immunosuppression, antibiotic use)
3. Inadequate treatment duration for recurrent cases
4. Misdiagnosis of bacterial vaginosis or trichomoniasis as candidiasis
5. Not considering mixed infections that may require additional treatment