What is the recommended treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

For uncomplicated vaginal candidiasis, either topical antifungal agents or a single 150 mg oral dose of fluconazole are equally effective first-line treatments, with both achieving >90% response rates. 1

Classification of Vaginal Candidiasis

• Vaginal candidiasis can be classified as either uncomplicated (90% of cases) or complicated (10% of cases) 1
• Complicated cases include severe or recurrent disease, infection due to non-albicans species, and/or infection in an abnormal host 1
• Candida albicans is the most common pathogen, but other Candida species can also cause this infection 1

Diagnosis

• Diagnosis should be confirmed before treatment through:
  • Wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1
  • Checking for normal vaginal pH (4.0-4.5) 1
  • Vaginal cultures for those with negative findings on microscopy 1

Treatment Recommendations

Uncomplicated Vaginal Candidiasis (90% of cases)

• Topical antifungal agents (no one agent superior to another) 1:

  • Clotrimazole 1% cream for 7-14 days or 100 mg vaginal tablet for 7 days 1
  • Miconazole 2% cream for 7 days or 200 mg vaginal suppository for 3 days 1
  • Butoconazole, terconazole, or tioconazole formulations 1

• Oral therapy option:

  • Fluconazole 150 mg as a single oral dose 1, 2

Complicated Vaginal Candidiasis (10% of cases)

Severe Acute Infection

• Fluconazole 150 mg every 72 hours for a total of 2-3 doses 1
• OR topical antifungal agents for 7-14 days 1

Non-albicans Candida Infections

• For C. glabrata infections (resistant to fluconazole) 1:
  • Boric acid 600 mg in gelatin capsule vaginally daily for 14 days 1
  • Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
  • Topical 17% flucytosine cream alone or with 3% amphotericin B cream daily for 14 days 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

• Initial induction therapy: 10-14 days of topical agent or oral fluconazole 1
• Followed by maintenance therapy: fluconazole 150 mg weekly for 6 months 1, 3
• This regimen achieves control of symptoms in >90% of patients 1
• Alternative maintenance regimens if fluconazole is not feasible:
  • Clotrimazole cream 200 mg twice weekly 1
  • Clotrimazole vaginal suppository 500 mg once weekly 1

Special Considerations

• Treatment should not differ based on HIV status; identical response rates are expected for HIV-positive and HIV-negative women 1
• After cessation of maintenance therapy for recurrent infections, a 40-50% recurrence rate can be anticipated 1
• Self-diagnosis of yeast vaginitis is unreliable; microscopic confirmation should be obtained before treatment 1, 4
• Treatment of sex partners is generally not recommended for most cases but may be considered for women with recurrent infections 1

Potential Adverse Effects and Drug Interactions

• Topical agents rarely cause systemic side effects but may cause local burning or irritation 1
• Oral azoles may cause nausea, abdominal pain, and headache 1
• Fluconazole may interact with several medications including astemizole, calcium channel antagonists, cisapride, coumadin, and protease inhibitors 1

Treatment Pitfalls to Avoid

• Failure to distinguish between uncomplicated and complicated infections can lead to inadequate treatment 1
• Not confirming diagnosis before treatment may lead to inappropriate therapy 1
• Inadequate duration of treatment may lead to recurrence of active infection 2
• Overlooking non-albicans species (especially C. glabrata) which require different treatment approaches 1
• Failing to implement maintenance therapy for truly recurrent cases 1