What is the treatment for candida vaginitis?

Treatment for Candida Vaginitis

For uncomplicated candida vaginitis, the first-line treatment options include either topical azole formulations or a single 150 mg oral dose of fluconazole, both with approximately 80% clinical cure rates. 1

Diagnostic Confirmation

Before initiating treatment, confirm diagnosis through:

• Clinical symptoms: pruritus, vaginal discharge, vulvar burning, dyspareunia
• Physical examination: erythema of vagina/vulva, white discharge
• Normal vaginal pH (≤4.5)
• Positive microscopic examination with 10% KOH showing yeast or pseudohyphae

Treatment Options

First-Line Treatments

Topical Azole Formulations:

• 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 a single dose 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 as a single-dose bioadhesive product 1

Oral Option:

• Fluconazole 150mg: single oral dose 1, 2

Clinical trials have shown that a single oral dose of fluconazole is as effective as 7-day intravaginal clotrimazole therapy, with clinical cure or improvement in 94% of fluconazole-treated patients at 14-day evaluation 3.

Alternative Treatment:

• Nystatin 100,000 units: daily for 14 days (topical) 1

Special Populations

Pregnancy

• Avoid oral fluconazole in the first trimester
• Use only topical azoles throughout pregnancy 1

HIV Infection

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

Recurrent Vulvovaginal Candidiasis (RVVC)

For patients with ≥4 episodes per year:

1. Initial therapy: 7-14 days of topical therapy or fluconazole 150mg repeated 3 days later
2. Maintenance therapy for 6 months with one of the following:
   • Clotrimazole 500mg vaginal suppositories once weekly
   • Fluconazole 100-150mg once weekly 1, 4

Studies show patients with recurrent vaginitis are significantly less likely to respond clinically and mycologically to standard treatments compared to those without a history of recurrent vaginitis 3, 5.

Complicated Cases

Non-albicans Candida Species

• Non-albicans species (particularly C. glabrata and C. krusei) may be resistant to azoles 1
• For suspected non-albicans infections, consider:
  • Longer duration therapy (7-14 days)
  • Topical intravaginal boric acid, 600mg daily for 14 days 1
  • Nystatin may be effective against non-albicans Candida species 6

Follow-up

• Response to therapy is typically rapid, with improvement in 48-72 hours 1
• No routine follow-up is needed if symptoms resolve
• Return for follow-up only if symptoms persist or recur within 2 months 4, 1

Common Pitfalls and Caveats

1. Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC experiencing recurrence of the same symptoms 4, 1

2. Persistent symptoms despite treatment may indicate:

   • Non-albicans Candida species
   • Alternative diagnoses
   • Need for culture confirmation 1

3. Side effects:

   • Topical therapy: rarely results in adverse effects; may cause local burning or irritation
   • Oral fluconazole: may cause gastrointestinal upset (nausea 7%, abdominal pain 6%, diarrhea 3%), headache (13%) 1, 2

4. Treatment failures may be related to:

   • Perianal colonization with Candida (consider as a source of recurrence) 7
   • Incorrect diagnosis
   • Non-compliance with treatment regimen