What is the treatment for vulvovaginitis?

Treatment for Vulvovaginitis

For uncomplicated vulvovaginal candidiasis (VVC), either topical antifungal agents or a single 150-mg oral dose of fluconazole are recommended as first-line treatments. 1

Treatment Options Based on Type of Vulvovaginitis

Candida Vulvovaginitis (Most Common Type)

Uncomplicated VVC:

• Topical antifungal options (no single agent is superior to others) 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, one tablet as 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
  • Terconazole 0.4% cream 5g intravaginally for 7 days 1
  • Terconazole 0.8% cream 5g intravaginally for 3 days 1
  • Terconazole 80mg vaginal suppository, one suppository for 3 days 1
  • Butoconazole 2% cream 5g intravaginally for 3 days 1
  • Tioconazole 6.5% ointment 5g intravaginally in a single application 1

• Oral option:

  • Fluconazole 150mg oral tablet, single dose 1

Severe Acute VVC:

• Fluconazole 150mg, given every 72 hours for a total of 2-3 doses 1

C. glabrata Vulvovaginitis (resistant to azoles):

• Topical intravaginal boric acid 600mg daily in a gelatin capsule for 14 days 1
• Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
• Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Recurrent VVC:

• 10-14 days of induction therapy with topical agent or oral fluconazole, followed by fluconazole 150mg weekly for 6 months 1

Non-Candida Vulvovaginitis

• For bacterial vulvovaginitis in children: improved anogenital hygiene, sitz/tub baths, and non-irritating soaps 2
• For specific bacterial infections: targeted antimicrobial therapy based on culture results 3
• For parasitic causes (e.g., Enterobius vermicularis): appropriate antiparasitic treatment 4

Special Considerations

For Children

• Vulvovaginitis in prepubertal girls is often non-specific and related to poor hygiene 5, 2
• Topical antibiotics may be preferable to systemic antibiotics to reduce side effects and bacterial resistance 3
• Candida infections are uncommon in otherwise healthy prepubertal girls 2
• Consider anatomical factors that predispose young girls to vulvovaginitis 5

For Pregnant Women

• Avoid oral azoles in the first trimester 1
• Topical azoles are generally considered safe during pregnancy 1

For Immunocompromised Patients

• May require longer duration of therapy or higher doses 1

Practical Considerations

• Over-the-counter preparations (butoconazole, clotrimazole, miconazole, tioconazole) are appropriate for women with previously diagnosed VVC who have recurrence of the same symptoms 1
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 1
• Patients should be instructed to return for follow-up only if symptoms persist or recur within 2 months 1
• Treatment of sexual partners is generally not recommended for VVC but may be considered for recurrent cases 1

Common Pitfalls to Avoid

• Treating Candida found on culture without symptoms (10-20% of women normally harbor Candida) 1
• Failing to identify non-albicans Candida species in recurrent cases, which may require different treatment approaches 1
• Inappropriate use of OTC preparations without proper diagnosis, which can delay treatment of other causes of vulvovaginitis 1
• Not considering other causes of vulvovaginitis such as bacterial infections, parasites, or foreign bodies in persistent cases 5, 4