What is the treatment for vulvovaginitis caused by yeast?

Treatment of Vulvovaginitis Caused by Yeast

For uncomplicated vulvovaginal candidiasis, either topical antifungal agents or a single 150-mg oral dose of fluconazole is strongly recommended as first-line treatment. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with:

• Clinical symptoms: pruritus, irritation, vaginal soreness, dyspareunia
• Physical signs: vulvar edema, erythema, white curdlike discharge
• Laboratory confirmation: wet-mount preparation with saline and 10% potassium hydroxide (KOH) to demonstrate yeast or hyphae
• Normal vaginal pH (≤4.5)

Treatment Options for Uncomplicated Cases

Topical Antifungal Options:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Clotrimazole 100mg vaginal tablet for 7 days 1
• Clotrimazole 500mg vaginal tablet, single application 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Miconazole 200mg vaginal suppository, one daily for 3 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1, 2
• Terconazole 0.8% cream 5g intravaginally for 3 days 1
• Butoconazole 2% cream 5g intravaginally for 3 days 1

Oral Option:

• Fluconazole 150mg oral tablet, single dose 1

Treatment for Severe Acute Vulvovaginitis

For severe acute cases:

• Fluconazole 150mg every 72 hours for a total of 2-3 doses 1

Special Considerations for C. glabrata Infections

C. glabrata often shows resistance to azoles 3. Treatment options include:

1. Topical intravaginal boric acid, 600mg daily for 14 days (strong recommendation) 1
2. Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
3. Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Management of Recurrent Vulvovaginal Candidiasis

For recurring vulvovaginal candidiasis:

1. Induction therapy with topical agent or oral fluconazole for 10-14 days
2. Followed by maintenance therapy with fluconazole 150mg weekly for 6 months 1

Clinical Pearls and Pitfalls

• Diagnostic pitfall: Symptoms of vulvovaginal candidiasis (pruritus, discharge, soreness) are nonspecific and can be caused by other conditions. Always confirm diagnosis before treatment 1, 4
• Treatment pitfall: Non-albicans Candida species (especially C. glabrata) are more common in recurrent cases (42% vs 20% in initial infections) and often require alternative treatments 3
• Self-treatment caution: Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Follow-up recommendation: If symptoms persist after 72 hours of appropriate therapy, consider alternative diagnosis 5

Treatment Algorithm

1. Uncomplicated first episode:

   • Either topical azole for 1-7 days OR
   • Single dose oral fluconazole 150mg

2. Severe acute episode:

   • Fluconazole 150mg every 72 hours for 2-3 doses

3. Suspected C. glabrata infection (not responding to azoles):

   • Boric acid 600mg intravaginally daily for 14 days

4. Recurrent vulvovaginal candidiasis:

   • Induction: 10-14 days of topical or oral therapy
   • Maintenance: Fluconazole 150mg weekly for 6 months

This evidence-based approach to treating vulvovaginal candidiasis focuses on proper diagnosis and targeted therapy based on clinical presentation and causative species, ensuring optimal outcomes for patients with this common condition.