Outpatient Management of Vulvovaginal Candidiasis (Yeast Infections)
For uncomplicated vulvovaginal candidiasis (VVC), both topical azole antifungals and oral fluconazole are highly effective first-line treatments with cure rates of 80-90%. 1, 2
Diagnosis
- Diagnosis should be confirmed through clinical symptoms plus either microscopic identification of yeast/pseudohyphae or positive culture, especially for recurrent cases 1, 3
- A normal vaginal pH (≤4.5) is typically present with VVC and should be checked before initiating treatment 3
Treatment Options for Uncomplicated VVC
Topical Azole Options:
- Clotrimazole 1% cream: 5g intravaginally daily for 7-14 days 1, 4
- Clotrimazole 2% cream: 5g intravaginally daily for 3 days 1, 4
- Miconazole 2% cream: 5g intravaginally daily for 7 days 1
- Terconazole vaginal cream: Apply locally as directed for vulvovaginal candidiasis 5
Oral Option:
- Fluconazole 150mg as a single oral dose 1, 2
- Clinical cure rates with oral fluconazole (69%) are comparable to topical azoles (72%) 2
Treatment Based on Severity
Mild to Moderate VVC:
- Either topical azole for 1-7 days or single-dose oral fluconazole 150mg 1, 3
- Both approaches achieve >90% response rates for uncomplicated infections 3
Severe VVC:
- Longer duration therapy (7-14 days) with topical azoles 1, 3
- OR fluconazole 150mg orally every 72 hours for a total of 2-3 doses 3
Special Populations
Pregnancy:
- Only topical azole therapy should be used during pregnancy 1
- Oral fluconazole during pregnancy has been associated with spontaneous abortion and should be avoided 1
HIV Infection:
- Treatment does not differ based on HIV status, with identical response rates expected 1, 3
- VVC rates increase when CD4+ T-cell counts are <200 cells/mm³ 1
Recurrent Vulvovaginal Candidiasis (RVVC)
RVVC is defined as ≥3 symptomatic episodes within 12 months and affects approximately 6 million women annually 1, 6
Initial Treatment:
- Induction therapy with topical agent or oral fluconazole for 10-14 days 3
Maintenance Therapy:
- Fluconazole 150mg weekly for 6 months is the first-line maintenance treatment 1, 7
- Weekly fluconazole maintenance therapy has been shown to keep 90.8% of women disease-free at 6 months compared to 35.9% with placebo 7
- Despite maintenance therapy, recurrence occurs in up to 50% of women after discontinuation 6
Non-albicans Candida Infections
- C. albicans accounts for approximately 74% of VVC cases, while C. glabrata accounts for about 20% 8
- For non-albicans Candida infections, boric acid 600mg in a gelatin capsule vaginally daily for 2 weeks is recommended 1, 3
- Non-albicans species may show reduced susceptibility to azoles, particularly at vaginal pH 1
Treatment Failures and Pitfalls
- Consider antifungal resistance if treatment fails, particularly with recurrent infections 9
- Ensure accurate diagnosis with culture confirmation for recurrent cases, as symptoms may mimic other conditions 1, 6
- Alternative treatments (honey-based products, essential oils) are generally inferior to conventional antifungals and are not recommended 1
- Premature discontinuation of therapy can lead to treatment failure; complete the full course even if symptoms improve 10
Emerging Treatments
- Oteseconazole (formerly VT-1161) is a promising novel oral treatment for RVVC, with phase 3 trials showing significantly lower recurrence rates (4%) compared to placebo (52%) 1
- A vaccine targeting Candida albicans has shown promise in reducing symptomatic VVC for up to 12 months in women under 40 years of age 1