What is the 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, 2

Classification and Diagnosis

• Vaginal candidiasis is classified as either uncomplicated (90% of cases) or complicated (10% of cases), with Candida albicans being the most common pathogen 1, 2
• Diagnosis should be confirmed before treatment through wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae, checking for normal vaginal pH (4.0-4.5) 1
• For negative findings on microscopy, vaginal cultures for Candida should be obtained 1

Treatment Algorithm

Uncomplicated Vaginal Candidiasis (90% of cases)

• First-line options (choose one):
  • Topical antifungal agents (no one agent superior to another) 1, 2
    • Examples: clotrimazole 1% cream for 7-14 days or 100 mg vaginal tablet for 7 days 2, 3
  • Oral fluconazole 150 mg as a single dose 1, 4
    • Clinical and mycological cure rates of 77% at 14 days post-treatment 5

Severe Acute Vaginal Candidiasis

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

Candida glabrata Infection (resistant to oral azoles)

• First option: Topical intravaginal boric acid in gelatin capsule, 600 mg daily for 14 days 1
• Second option: Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
• Third option: Topical 17% flucytosine cream alone or combined with 3% AmB 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, 2
• Followed by maintenance therapy: fluconazole 150 mg weekly for 6 months 1, 2
• Note: 40-50% recurrence rate can be anticipated after cessation of maintenance therapy 2

Special Considerations

• Treatment efficacy is not affected by HIV status, with identical response rates expected for HIV-positive and HIV-negative women 1, 2
• Patients with recurrent vaginitis (≥4 episodes/12 months) have lower cure rates (57% clinical cure, 47% mycologic eradication) compared to those with acute vaginitis (80% clinical cure, 67% mycologic eradication) 4, 5
• Self-diagnosis of yeast vaginitis is unreliable; microscopic confirmation should be obtained before treatment 2

Potential Adverse Effects

• Topical agents: Rarely cause systemic side effects but may cause local burning or irritation 2, 6
• Oral fluconazole:
  • Common side effects include headache (13%), nausea (7%), and abdominal pain (6%) 4
  • Other side effects include diarrhea (3%), dyspepsia (1%), dizziness (1%) 4
  • Rarely, hepatic reactions ranging from mild transient elevations in transaminases to clinical hepatitis and fulminant hepatic failure have been reported 4

Clinical Pearls

• Topical and oral antifungal formulations have been shown to achieve equivalent results for uncomplicated cases 1, 7
• The choice between topical and oral therapy can be based on patient preference, as efficacy is similar 5, 8
• For complicated infections, identification of the causative agent is important since some species (C. glabrata, C. krusei) may not respond to fluconazole 1, 9
• Treatment of chronic vulvovaginal candidiasis should include identification and clearance of existing endogenous (oral cavity, intestine) and exogenous (sex partner) sources of reinfection 9