What is the recommended treatment for vaginal yeast infections?

Treatment of Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, either a single 150 mg oral dose of fluconazole or a topical antifungal agent is recommended as first-line therapy, with both options showing equivalent efficacy. 1

Classification of Vaginal Yeast Infections

Vulvovaginal candidiasis (VVC) can be classified into two categories:

• Uncomplicated VVC (90% of cases): Mild-to-moderate, sporadic, non-recurrent disease in a normal host with normally susceptible Candida albicans 1
• Complicated VVC (10% of cases): Severe or recurrent disease, infection due to non-albicans species, and/or infection in an abnormal host 1

Diagnosis

Before initiating treatment, confirm the diagnosis by:

• Identifying symptoms: pruritus, irritation, vaginal soreness, dyspareunia, and vaginal discharge 1
• Performing a wet mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or pseudohyphae 1
• Checking vaginal pH (should be normal at ≤4.5) 1
• Obtaining vaginal cultures for Candida if wet mount is negative but symptoms suggest VVC 1

Treatment Recommendations

For Uncomplicated VVC:

Topical Options 1:

• Butoconazole 2% cream 5g intravaginally for 3 days 1
• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Clotrimazole 100mg vaginal tablet for 7 days 1
• Clotrimazole 100mg vaginal tablet, two tablets for 3 days 1
• Clotrimazole 500mg vaginal tablet, one tablet in a single application 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Miconazole 200mg vaginal suppository, one suppository for 3 days 1
• Miconazole 100mg vaginal suppository, one suppository for 7 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1
• Terconazole 0.8% cream 5g intravaginally for 3 days 1
• Terconazole 80mg vaginal suppository, one suppository for 3 days 1
• Tioconazole 6.5% ointment 5g intravaginally in a single application 1

Oral Option:

• Fluconazole 150mg oral tablet, one tablet in single dose 1, 2

For Severe VVC:

• Fluconazole 150mg, given every 72 hours for a total of 2 or 3 doses 1, 3
• Alternatively, 7-14 days of topical azole therapy 1

For C. glabrata Infections (resistant to fluconazole):

• Boric acid 600mg in a gelatin capsule, administered vaginally once daily for 14 days 1
• Nystatin 100,000-unit vaginal suppositories daily for 14 days 1
• Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

For Recurrent VVC:

• Initial induction therapy with 10-14 days of a topical agent or oral fluconazole 1
• Followed by maintenance therapy with fluconazole 150mg weekly for 6 months 1

Clinical Considerations

• Topical and oral azole treatments show equivalent efficacy (80-90% response rates) 1, 4
• Patient preference may guide the choice between oral and topical therapy 4, 5
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Women whose symptoms persist after using an OTC preparation or who have recurrence within 2 months should seek medical care 1

Special Populations

Pregnancy:

• Only topical azole therapies applied for 7 days are recommended during pregnancy 1

HIV Infection:

• Treatment for VVC in HIV-infected women should not differ from that for HIV-negative women 1
• Long-term prophylactic therapy with fluconazole is not recommended for routine primary prophylaxis in HIV-infected women without recurrent VVC 1

Women with Underlying Medical Conditions:

• Women with underlying conditions (e.g., uncontrolled diabetes, corticosteroid treatment) may not respond as well to short-term therapies 1
• More prolonged (7-14 days) conventional antimycotic treatment is necessary 1

Common Pitfalls to Avoid

• Treating asymptomatic Candida colonization (found in 10-20% of women) is not recommended 1
• Failing to consider non-albicans Candida species in cases of treatment failure 1, 3
• Not recognizing that women with a history of recurrent vaginitis are less likely to respond to standard therapy 4
• Overlooking the need for longer duration therapy in complicated cases 3