What is the treatment for vaginal yeast infections?

Treatment of Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, either topical antifungal agents or a single 150 mg oral dose of fluconazole are equally effective first-line treatments. 1

Diagnosis

Before initiating treatment, confirm diagnosis with:

• Clinical symptoms: pruritus, irritation, vaginal soreness, external dysuria, dyspareunia, and vaginal discharge 1
• Physical signs: vulvar edema, erythema, excoriation, fissures, and white thick curd-like discharge 1
• Laboratory confirmation: wet-mount preparation with saline and 10% KOH showing yeast or hyphae with normal vaginal pH (4.0-4.5) 1
• Vaginal cultures for Candida if wet mount is negative but symptoms persist 1

Treatment Algorithm

Uncomplicated Vulvovaginal Candidiasis (90% of cases)

• Option 1: Topical antifungal agents (no one agent superior to another) 1

  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
  • Clotrimazole 100mg vaginal tablet for 7 days 1
  • Clotrimazole 100mg vaginal tablet, two tablets for 3 days 1
  • Clotrimazole 500mg vaginal tablet, single application 1
  • Miconazole 2% cream 5g intravaginally for 7 days 1
  • Miconazole 200mg vaginal suppository, one suppository for 3 days 1
  • Miconazole 100mg vaginal suppository, one suppository for 7 days 1
  • Other options: butoconazole, tioconazole, terconazole 1

• Option 2: Oral therapy 1

  • Fluconazole 150mg oral tablet, single dose 1, 2

Complicated Vulvovaginal Candidiasis (10% of cases)

Defined as severe/recurrent disease, non-albicans infection, or abnormal host factors 1

Severe acute infection:

• Fluconazole 150mg every 72 hours for 2-3 doses 1
• OR topical therapy for 7-14 days 1

C. glabrata infection (resistant to fluconazole):

• Boric acid 600mg in gelatin capsule intravaginally daily for 14 days 1
• OR nystatin 100,000-unit vaginal suppositories daily for 14 days 1
• OR topical 17% flucytosine cream alone or with 3% amphotericin B cream daily for 14 days 1

Recurrent vulvovaginal candidiasis (≥4 episodes/year):

• Initial: 10-14 days induction with topical agent or oral fluconazole 1
• Maintenance: fluconazole 150mg weekly for 6 months 1
• Alternative maintenance: clotrimazole cream 200mg twice weekly or clotrimazole vaginal suppository 500mg once weekly 1

Efficacy Comparison

• Both topical and oral treatments achieve 80-90% symptom relief and negative cultures 1, 3
• Single-dose fluconazole (150mg) is as effective as 7-day clotrimazole therapy with clinical cure rates of 94% vs 97% at 14 days 3
• Fluconazole may relieve symptoms more rapidly than topical treatments 4

Special Considerations

Pregnancy

• Topical azole therapies are preferred during pregnancy 1

HIV Infection

• Treatment should not differ based on HIV status; identical response rates are expected 1

Self-medication

• Self-treatment with OTC preparations is appropriate only for women previously diagnosed with yeast infections who have recurrence of the same symptoms 1
• Women with persistent symptoms after OTC treatment or recurrence within 2 months should seek medical care 1

Common Pitfalls to Avoid

• Treating without confirming diagnosis can lead to inappropriate therapy and delayed treatment of other conditions 1
• Self-diagnosis is unreliable and can lead to overuse of antifungal agents 1
• Identifying Candida in culture without symptoms should not lead to treatment (10-20% of women normally harbor Candida) 1
• Patients with history of recurrent vaginitis are less likely to respond to standard therapy and may need longer treatment courses 3