What is the treatment for a Candida (fungal) infection in the vagina?

Treatment of Vaginal Candida Infection

For uncomplicated vulvovaginal candidiasis, either oral fluconazole 150 mg as a single dose or topical azole therapy for 3-7 days are equally effective first-line treatments with >90% response rates. 1

Diagnosis Confirmation

• Diagnosis should be confirmed through wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1
• Normal vaginal pH (4.0-4.5) is associated with Candida infection 1
• Vaginal cultures should be obtained for patients with negative microscopy findings but suspected infection 1
• Identifying Candida without symptoms should not lead to treatment as 10-20% of women normally harbor Candida in the vagina 1

Treatment Options Based on Severity

Uncomplicated Infection (90% of cases)

• Topical options (all equally effective):

  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
  • Clotrimazole 100mg vaginal tablet for 7 days 1
  • Miconazole 2% cream 5g intravaginally for 7 days 1
  • Butoconazole 2% cream 5g intravaginally for 3 days 1
  • Tioconazole 6.5% ointment 5g intravaginally as single application 1

• Oral option:

  • Fluconazole 150mg as a single oral dose 1, 2
  • Clinical cure rates of 69% and mycological eradication rates of 61% 2

Complicated Infection (10% of cases)

• Severe infection:

  • Fluconazole 150mg every 72 hours for 3 doses 1
  • Topical azole therapy for 7-14 days 1

• Non-albicans Candida infection:

  • For C. glabrata: Boric acid 600mg in gelatin capsule vaginally daily for 14 days 1
  • Alternative for C. glabrata: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
  • For refractory cases: Topical 17% flucytosine cream alone or with 3% AmB cream for 14 days 1

• Recurrent vulvovaginal candidiasis (≥4 episodes in 12 months):

  • Initial induction therapy with topical agent or oral fluconazole for 10-14 days 1
  • Followed by maintenance therapy with fluconazole 150mg weekly for 6 months 1, 3
  • This regimen achieves control of symptoms in >90% of patients 1
  • After stopping maintenance therapy, 40-50% recurrence rate can be expected 1

Patient Preferences and Special Considerations

• Approximately half of patients prefer oral medication while only 5% prefer intravaginal therapy 4
• Treatment of vulvovaginal candidiasis should not differ based on HIV status 1
• Fluconazole should not be used during the first trimester of pregnancy 1
• Most common side effects of oral fluconazole include headache (13%), nausea (7%), and abdominal pain (6%) 2

Treatment Pitfalls and Caveats

• Self-diagnosis and treatment without confirmation can lead to inappropriate therapy 5
• For therapy-resistant cases, non-albicans infection should be ruled out before changing treatment approach 3
• Azole-resistant C. albicans infections are extremely rare but can occur after prolonged azole exposure 1
• Over-the-counter preparations should only be recommended 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

Follow-up

• For uncomplicated infections with symptom resolution, follow-up is generally unnecessary 1
• For recurrent infections, follow-up during maintenance therapy is important to ensure symptom control 3