What is the treatment for vulvovaginitis?

Treatment of Vulvovaginitis

The treatment of vulvovaginitis depends on the specific cause, with topical azole medications being the first-line therapy for vulvovaginal candidiasis (VVC), oral metronidazole for bacterial vaginosis, and oral metronidazole or tinidazole for trichomoniasis. 1, 2

Vulvovaginal Candidiasis (VVC)

Uncomplicated VVC

• Short-course topical azole formulations (1-3 days) or single-dose oral fluconazole (150 mg) effectively treat uncomplicated VVC with 80-90% success rates 1
• Recommended topical treatments include:
  • Clotrimazole 1% cream for 7-14 days or clotrimazole vaginal tablets (100 mg for 7 days or 500 mg as single application) 1
  • Miconazole 2% cream for 7 days or miconazole vaginal suppositories (100 mg for 7 days or 200 mg for 3 days) 1
  • Butoconazole, terconazole, or tioconazole preparations as directed 1
• Oral option: Fluconazole 150 mg single oral dose 1

Complicated VVC

Severe VVC

• For extensive vulvar erythema, edema, excoriation, and fissure formation: 1
  • Extended topical azole therapy (7-14 days) OR
  • Fluconazole 150 mg oral dose repeated after 72 hours 1

Recurrent VVC (RVVC)

• Defined as 4 or more symptomatic episodes per year, affects <5% of women 1, 3
• Initial therapy: Longer duration treatment (7-14 days topical or fluconazole 150 mg oral repeated after 3 days) 1
• Maintenance therapy (for 6 months): 1, 3
  • Fluconazole 100-150 mg weekly OR
  • Clotrimazole 500 mg vaginal suppositories weekly OR
  • Ketoconazole 100 mg daily (monitor for hepatotoxicity) OR
  • Itraconazole 400 mg monthly or 100 mg daily 1

Non-albicans VVC

• Longer duration (7-14 days) with non-fluconazole azole drugs 1
• For recurrence: Boric acid 600 mg in gelatin capsule vaginally daily for 2 weeks (70% eradication rate) 1
• For persistent recurrence: Nystatin 100,000 units daily via vaginal suppositories 1

Special Populations

• Pregnancy: Only topical azole therapies for 7 days are recommended 1
• Compromised hosts (uncontrolled diabetes, corticosteroid treatment): Extended 7-14 day treatment course 1
• HIV infection: Treatment same as for seronegative women, but higher recurrence rates may occur 1

Bacterial Vaginosis

• First-line treatment: Oral metronidazole 500 mg twice daily for 7 days 2, 4
• Alternatives: Intravaginal metronidazole gel or intravaginal clindamycin cream 2
• For recurrent cases: Longer courses of therapy are recommended 3

Trichomoniasis

• Standard treatment: Single 2-g oral dose of metronidazole 4
• Alternative: Metronidazole 500 mg twice daily for 7 days (similar 88% cure rate) 3
• Always treat sex partners simultaneously to enhance cure rates 3
• For resistant cases: Higher-dose therapy may be needed 3

Follow-Up Considerations

• Patients should return only if symptoms persist or recur within 2 months 1
• For recurrent VVC, vaginal cultures should be obtained to confirm diagnosis and identify unusual species 1
• Treatment of sex partners is generally not recommended for VVC but may be considered for recurrent cases 1
• Male partners with balanitis (erythematous areas on glans with pruritus) benefit from topical antifungal treatment 1

Common Pitfalls and Caveats

• OTC antifungal preparations should only be recommended for women previously diagnosed with VVC experiencing recurrence of identical symptoms 1
• Inappropriate self-treatment with OTC products can delay proper diagnosis and treatment of other causes of vulvovaginitis 1
• Antibiotics are a common trigger for VVC, with prophylactic antifungals sometimes warranted during antibiotic therapy 5
• Identifying Candida without symptoms should not lead to treatment (10-20% of women normally harbor Candida) 1
• Azole creams and suppositories are oil-based and may weaken latex condoms and diaphragms 1