What is the treatment for vulvovaginal candidiasis?

Treatment for 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, 2

Classification and Diagnosis

• Vulvovaginal candidiasis (VVC) can be classified as either uncomplicated (90% of cases) or complicated (10% of cases), based on clinical presentation, microbiological findings, host factors, and response to therapy 1, 2
• Uncomplicated VVC typically presents in immunocompetent women with mild-to-moderate symptoms and is usually caused by Candida albicans 1
• Complicated VVC includes severe disease, recurrent infections (≥4 episodes/12 months), non-albicans species infections, or infection in abnormal hosts 1, 2
• Diagnosis should be confirmed before treatment through:
  • Clinical evaluation for symptoms (pruritus, irritation, vaginal discharge, soreness, dyspareunia) 1
  • Physical examination for signs (vulvar edema, erythema, excoriation, white discharge) 1
  • Laboratory confirmation with wet-mount preparation using saline and 10% potassium hydroxide to demonstrate yeast/hyphae 1, 2
  • Vaginal cultures for patients with negative wet-mount findings or suspected non-albicans species 1

Treatment Algorithm for Uncomplicated VVC

First-line options (equally effective):

1. Topical antifungal agents 1:

   • Butoconazole 2% cream 5g intravaginally for 3 days
   • Clotrimazole 1% cream 5g intravaginally for 7-14 days
   • Clotrimazole 100mg vaginal tablet for 7 days
   • Clotrimazole 100mg vaginal tablet, two tablets for 3 days
   • Clotrimazole 500mg vaginal tablet, one tablet single application
   • Miconazole 2% cream 5g intravaginally for 7 days
   • Miconazole 200mg vaginal suppository, one suppository for 3 days
   • Miconazole 100mg vaginal suppository, one suppository for 7 days
   • Tioconazole 6.5% ointment 5g intravaginally in a single application
   • Terconazole 0.4% cream 5g intravaginally for 7 days
   • Terconazole 0.8% cream 5g intravaginally for 3 days
   • Terconazole 80mg vaginal suppository, one suppository for 3 days

2. Oral therapy 1, 3:

   • Fluconazole 150mg oral tablet, single dose

Treatment for Severe Acute VVC

• For severe acute VVC, fluconazole 150mg, given every 72 hours for a total of 2 or 3 doses is recommended 1, 2

Treatment for Complicated VVC

Non-albicans species (e.g., C. glabrata):

• For C. glabrata vulvovaginitis unresponsive to oral azoles, options include 1:
  • Topical intravaginal boric acid, 600mg daily in a gelatin capsule, for 14 days
  • Nystatin intravaginal suppositories, 100,000 units daily for 14 days
  • Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days

Recurrent VVC:

• For recurring VVC, 10-14 days of induction therapy with a topical agent or oral fluconazole, followed by fluconazole 150mg weekly for 6 months 1, 4
• This maintenance regimen has shown effectiveness with 90.8% of women remaining disease-free at 6 months compared to 35.9% with placebo 4
• The median time to clinical recurrence with maintenance fluconazole is 10.2 months versus 4.0 months with placebo 4

Special Considerations

• Treatment should not differ based on HIV status, with identical response rates expected for HIV-positive and HIV-negative women 1, 2
• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Women whose symptoms persist after using OTC preparations or who experience recurrence within 2 months should seek medical care 1

Common Pitfalls and Caveats

• Misdiagnosis is common as symptoms are nonspecific and can be caused by various infectious and non-infectious conditions 1, 2
• Laboratory confirmation is essential, especially for recurrent cases 1, 5
• Inadequate treatment duration is problematic, particularly for complicated VVC which requires longer courses than uncomplicated VVC 2
• Despite maintenance therapy, recurrence rates of 40-50% are common after discontinuation of treatment 4, 6
• Fluconazole may cause side effects including headache (13%), nausea (7%), and abdominal pain (6%), though most are mild to moderate 3