Treatment Regimen for Vulvovaginal Candidiasis Requiring Azo, Fluconazole, and Boric Acid
For patients with symptoms requiring Azo (phenazopyridine), fluconazole, and boric acid suppository, the recommended treatment approach is oral fluconazole 150 mg every 72 hours for 3 doses, plus boric acid 600 mg vaginal suppositories daily for 14 days, with phenazopyridine for symptomatic relief until urinary symptoms resolve.
Diagnosis and Assessment
- Before initiating treatment, confirm the diagnosis of vulvovaginal candidiasis (VVC) through wet-mount preparation with saline and 10% potassium hydroxide to demonstrate the presence of yeast or hyphae and verify normal vaginal pH (4.0–4.5) 1
- Determine if the infection is uncomplicated or complicated VVC, as this affects treatment approach 1
- Consider the possibility of non-albicans Candida species, particularly C. glabrata, which often requires boric acid therapy 1
Treatment Protocol
For Uncomplicated VVC (C. albicans):
- Fluconazole 150 mg orally as a single dose 1
- Phenazopyridine (Azo) 100-200 mg orally three times daily for 1-2 days for symptomatic relief of urinary symptoms 1
For Complicated VVC (Severe symptoms, C. glabrata, or recurrent infection):
- Fluconazole 150 mg orally every 72 hours for a total of 2-3 doses 1
- Boric acid 600 mg vaginal suppositories daily for 14 days, especially for C. glabrata infections 1, 2
- Phenazopyridine (Azo) 100-200 mg orally three times daily until urinary symptoms resolve 1
Special Considerations
For C. glabrata Infections:
- Boric acid is significantly more effective than fluconazole for C. glabrata VVC, with mycological cure rates of 63.6% vs. 28.6% respectively 2
- Boric acid inhibits C. glabrata growth across many isolates and morphologies 3
- Continue boric acid suppositories for the full 14-day course even if symptoms improve earlier 1, 2
For Recurrent VVC:
- After initial treatment with fluconazole and boric acid, consider maintenance therapy with fluconazole 150 mg weekly for 6 months 1, 4
- Weekly fluconazole maintenance therapy can keep 90.8% of women disease-free at 6 months compared to 35.9% with placebo 4
Monitoring and Follow-up
- Patients should return for follow-up only if symptoms persist or recur within 2 months 1
- For patients with diabetes, be aware that only about 46.6% remain cured at 3 months after a 14-day course of boric acid therapy 5
- If symptoms persist despite appropriate therapy, consider alternative diagnoses or resistant organisms 1
Clinical Pearls and Pitfalls
- Phenazopyridine (Azo) provides symptomatic relief only and does not treat the underlying infection; it should always be used in conjunction with antifungal therapy 1
- Boric acid suppositories must be compounded by a pharmacist for specific patient use 1
- Boric acid is particularly effective against C. glabrata, which often responds poorly to azole drugs 1, 2
- Oil-based vaginal creams and suppositories may weaken latex condoms and diaphragms 1
- Identifying Candida in vaginal cultures without symptoms should not lead to treatment, as 10-20% of women normally harbor Candida species 1