From the Guidelines
Alternative treatments to fluconazole for vulvovaginal candidiasis include over-the-counter intravaginal agents such as clotrimazole, miconazole, and tioconazole, as well as prescription intravaginal agents like butoconazole and terconazole. These treatments have been recommended in the 2021 Centers for Disease Control and Prevention (CDC) treatment guidelines for sexually transmitted infections, as outlined in a review of the evidence published in Clinical Infectious Diseases in 2022 1.
Treatment Options
The following treatment options are available:
- Over-the-counter intravaginal agents:
- Clotrimazole 1% cream: 5 g intravaginally daily for 7–14 days
- Clotrimazole 2% cream: 5 g intravaginally daily for 3 days
- Miconazole 2% cream: 5 g intravaginally daily for 7 days
- Miconazole 4% cream: 5 g intravaginally daily for 3 days
- Miloconjec 100 mg vaginal suppository: one suppository daily for 7 days
- Miconazole 200 mg vaginal suppository: one suppository for 3 days
- Miconazole 1200 mg vaginal suppository: one suppository for 1 day
- Tioconazole 6.5% ointment: 5 g intravaginally in a single application
- Prescription intravaginal agents:
- Butoconazole 2% cream (single dose bioadhesive product): 5 g intravaginally in a single application
- Terconazole 0.4% cream: 5 g intravaginally daily for 7 days
- Terconazole 0.8% cream: 5 g intravaginally daily for 3 days
- Terconazole 80 mg vaginal suppository: one suppository daily for 3 days
Diagnosis and Treatment
It is essential to note that microscopy and clinical diagnosis have poor sensitivity, while yeast cultures can lead to a delay in diagnosis and treatment 1. Therefore, many providers rely on microscopy or clinical diagnosis for patients presenting with symptoms consistent with vulvovaginal candidiasis. However, this approach may result in misdiagnosis and unnecessary treatment. Molecular testing, such as polymerase chain reaction (PCR), has been found to have high clinical accuracy for diagnosing vulvovaginal candidiasis 1.
Choosing a Treatment
The choice of treatment depends on various factors, including pregnancy status, infection severity, medication allergies, and personal preference regarding oral versus topical application. It is crucial to consult a healthcare provider to determine the best course of treatment for each individual case.
From the FDA Drug Label
Terconazole vaginal cream 0.4% is indicated for the local treatment of vulvovaginal candidiasis (moniliasis) Alternative treatments for vulvovaginal candidiasis besides fluconazole (Diflucan) include:
- Terconazole vaginal cream 0.4% 2 Terconazole is effective for the local treatment of vulvovaginal candidiasis.
From the Research
Alternative Treatments for Vulvovaginal Candidiasis
Besides fluconazole (Diflucan), several alternative treatments are available for vulvovaginal candidiasis, including:
- Topical treatments such as clotrimazole, miconazole, terconazole, and intravaginal boric acid, as suggested by a panel of vulvovaginal experts 3
- Local preparations like Nizoral, Canesten, Gyno-Daktarine, and Gyno-Pevaryl, which have been used to treat acute vaginal yeast infections with a success rate of 84-90% 4
- Systemic antifungal agents like itraconazole, terbinafine, and nystatin, which have been compared to fluconazole in terms of their effectiveness in treating vulvovaginal candidiasis 5, 6
- Combined systemic and topical therapy, such as the use of fluconazole and metronidazole + clotrimazole, which has been proposed as a new approach to the treatment and prophylaxis of recurrent candidiasis 7
Specific Treatment Options
Some specific treatment options that have been studied include:
- Terbinafine, which has been shown to be an alternative treatment option for vulvovaginal candidiasis, although it may not be as effective as fluconazole or itraconazole 6
- Itraconazole, which has been compared to fluconazole and terbinafine in terms of its effectiveness in treating vulvovaginal candidiasis 6
- Intravaginal boric acid, which has been suggested as a treatment option for recurrent vulvovaginitis caused by both Candida albicans and nonalbicans species 3
Considerations for Treatment
When choosing a treatment option, it is important to consider the following factors:
- The type of Candida species present, as some treatments may be more effective against certain species than others 3, 5
- The patient's prior response to treatment, as this can influence the choice of treatment 3
- The potential for drug resistance, as the use of antifungal agents can contribute to the development of resistance 5
- The patient's pregnancy status, as some treatments may not be suitable for use during pregnancy 3, 4