What is the recommended treatment for Candida (C) albicans vaginitis?

Treatment of Candida albicans Vaginitis

For uncomplicated Candida albicans vaginitis, either a single 150 mg oral dose of fluconazole or a short course of topical azole therapy is recommended as first-line treatment, with both approaches showing equivalent efficacy rates of >90%. 1, 2

Classification and Diagnosis

• Vulvovaginal candidiasis (VVC) is caused by C. albicans in approximately 80-90% of cases, with non-albicans species accounting for the remainder 2
• Diagnosis should be confirmed by wet-mount preparation with saline and 10% KOH to demonstrate yeast or pseudohyphae, along with a normal vaginal pH (4.0-4.5) 2
• Symptoms include pruritus, vaginal discharge, vaginal soreness, vulvar burning, dyspareunia, and external dysuria 2
• VVC can be classified as uncomplicated (mild-to-moderate, sporadic, non-recurrent) or complicated (severe, recurrent, non-albicans species, or abnormal host) 1

Treatment Algorithm for C. albicans Vaginitis

First-line options for uncomplicated VVC:

1. Oral therapy:

   • Fluconazole 150 mg oral tablet, single dose 2
   • Clinical cure rates of 94-99% at short-term evaluation 3, 4

2. Topical intravaginal options:

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

For complicated VVC:

1. Severe vulvovaginitis:

   • Fluconazole 150 mg every 72 hours for 2-3 doses 2, 1
   • OR 7-14 days of topical azole therapy 2
   • Studies show significantly higher clinical cure rates with two sequential doses of fluconazole compared to a single dose for severe vaginitis 6

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

   • Initial induction therapy: 10-14 days of topical therapy or fluconazole 150 mg repeated after 3 days 2
   • Maintenance therapy: Fluconazole 100-150 mg once weekly for 6 months 2
   • Alternative maintenance regimens: Clotrimazole 500 mg vaginal suppositories once weekly 2

3. Non-albicans Candida species:

   • Longer duration (7-14 days) with non-fluconazole azole drug 2
   • For C. glabrata: 600 mg boric acid in gelatin capsule vaginally once daily for 2 weeks 2
   • Alternative options include topical 17% flucytosine cream alone or with 3% amphotericin B cream 2

Special Considerations

• Pregnancy: Only topical azole therapies applied for 7 days are recommended during pregnancy 2
• HIV infection: Treatment should not differ based on HIV status, with identical response rates expected for HIV-positive and HIV-negative women 2, 1
• Compromised hosts: Women with underlying conditions (e.g., uncontrolled diabetes, corticosteroid treatment) require more prolonged (7-14 days) antimycotic treatment 2

Common Pitfalls and Caveats

• Oil-based creams and suppositories may weaken latex condoms and diaphragms 2
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who have a recurrence of the same symptoms 2
• Women whose symptoms persist after using OTC preparations or who have recurrence within 2 months should seek medical care 2
• Fluconazole side effects include headache (13%), nausea (7%), and abdominal pain (6%) 7
• Terconazole side effects include headache (26%), body pain (2.1%), and vulvovaginal burning/itching 5
• Identifying Candida by culture in asymptomatic women should not lead to treatment, as 10-20% of women normally harbor Candida species in the vagina 2
• After cessation of maintenance therapy for recurrent VVC, a 40-50% recurrence rate can be anticipated 2, 1