What is the management for vulvovaginal candidiasis?

Management of Vulvovaginal Candidiasis

For uncomplicated vulvovaginal candidiasis, either topical antifungal agents or a single 150-mg oral dose of fluconazole is recommended as first-line therapy, with both approaches showing equivalent efficacy of >90% response. 1

Classification and Diagnosis

Vulvovaginal candidiasis (VVC) can be classified as:

• Uncomplicated VVC (90% of cases): Typically caused by Candida albicans in immunocompetent women with mild to moderate symptoms and infrequent episodes 1
• Complicated VVC (10% of cases): Includes severe symptoms, recurrent disease (≥4 episodes/year), non-albicans Candida species, or infection in an abnormal host 1

Proper diagnosis requires:

• Clinical evaluation for symptoms: pruritus, irritation, vaginal soreness, external dysuria, dyspareunia, and vaginal discharge 1
• Physical examination for signs: vulvar edema, erythema, excoriation, fissures, and thick, white, curd-like discharge 1
• Laboratory confirmation: wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae with normal pH (4.0-4.5) 1
• Vaginal cultures for patients with negative wet-mount findings or suspected non-albicans species 1

Treatment Algorithm

1. Uncomplicated VVC

First-line options (choose one):

• Topical antifungal agents (no superiority among options): Apply for 1-7 days depending on formulation 1

  • Clotrimazole, miconazole, terconazole, or other azole preparations 2

• Oral fluconazole: Single 150-mg dose 1, 3

  • Achieves >90% response rate 1
  • Convenient single-dose regimen 3

2. Severe Acute VVC

• Fluconazole 150 mg every 72 hours for 2-3 doses 1

3. Complicated VVC with Non-albicans Species

For C. glabrata infections unresponsive to oral azoles:

• First option: Topical intravaginal boric acid in gelatin capsules, 600 mg daily for 14 days 1
• Second option: Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
• Third option: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 1

For C. krusei infections:

• Any topical antifungal agent (C. krusei responds to all topical agents) 1

4. Recurrent VVC (≥4 episodes/year)

• Initial induction phase: Topical agent or oral fluconazole for 10-14 days 1

• Maintenance phase: Fluconazole 150 mg weekly for 6 months 1, 4

  • Achieves control of symptoms in >90% of patients 1
  • After cessation, 40-50% recurrence rate can be expected 1

• Alternative maintenance options (if fluconazole not feasible):

  • Topical clotrimazole cream, 200 mg twice weekly 1
  • Clotrimazole vaginal suppository, 500 mg once weekly 1

Special Considerations

• HIV status: Treatment should not differ based on HIV status; identical response rates are expected for HIV-positive and HIV-negative women 1

• Azole resistance: Resistance in C. albicans is rare but may develop following prolonged azole exposure 1, 5

• Potential side effects of oral fluconazole:

  • Common: headache (13%), nausea (7%), abdominal pain (6%), diarrhea (3%) 3
  • Rare: hepatic reactions, especially in patients with serious underlying conditions 3

• Monitoring for recurrence: After maintenance therapy, close follow-up is recommended as recurrence rates of 40-50% are common 1, 6

Common Pitfalls and Caveats

• Misdiagnosis: Symptoms of VVC are nonspecific and can be caused by various infectious and non-infectious etiologies; laboratory confirmation is essential, especially for recurrent cases 1, 6

• Inadequate treatment duration: Complicated VVC requires longer treatment courses than uncomplicated VVC 1

• Failure to identify non-albicans species: These often require different treatment approaches as they may be resistant to standard azole therapy 1, 7

• Overlooking contributing factors: Conditions such as diabetes, although rare, should be evaluated in recurrent cases 1, 6

• Premature discontinuation of maintenance therapy: For recurrent VVC, complete 6-month maintenance therapy is crucial for symptom control 1, 4