What is the recommended treatment for a vaginal yeast infection?

Treatment of Vaginal Yeast Infection

For uncomplicated vaginal yeast infections, either a single 150 mg oral dose of fluconazole or a topical antifungal agent is recommended as first-line therapy, with no one topical agent showing superiority over others. 1

Classification of Vaginal Yeast Infections

Vulvovaginal candidiasis (VVC) can be classified into two categories:

• Uncomplicated VVC (90% of cases): Mild-to-moderate, sporadic, non-recurrent disease in a normal host with normally susceptible Candida albicans 1
• Complicated VVC (10% of cases): Severe or recurrent disease, infection due to non-albicans species, and/or infection in an abnormal host 1

Diagnostic Considerations

Before initiating treatment, confirm the diagnosis:

• Look for symptoms including pruritus, irritation, vaginal soreness, external dysuria, and dyspareunia 1
• Physical examination may reveal vulvar edema, erythema, excoriation, fissures, and a white, thick, curd-like vaginal discharge 1
• Perform wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1
• Confirm normal vaginal pH (4.0-4.5) 1
• For negative findings, obtain vaginal cultures for Candida 1

Treatment Recommendations for Uncomplicated VVC

Oral Option:

• Fluconazole 150 mg oral tablet, single dose 1, 2
  • Achieves >90% response rate 1
  • Convenient single-dose regimen improves compliance 3
  • Therapeutic concentrations in vaginal secretions are rapidly achieved 3

Topical Options (all equally effective):

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

Treatment for Severe Acute VVC

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

Treatment for C. glabrata Vulvovaginitis (Azole-Resistant)

For C. glabrata infections unresponsive to oral azoles:

1. First option: Topical intravaginal boric acid in a gelatin capsule, 600 mg daily for 14 days 1
2. Second option: Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
3. Third option: Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Management of Recurrent Vulvovaginal Candidiasis

For recurring VVC (defined as ≥4 episodes within one year):

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

Special Considerations

• Pregnancy: Use topical azoles rather than oral fluconazole due to potential risks 1
• HIV infection: Treatment should not differ based on HIV status; identical response rates are anticipated 1
• Self-medication with OTC preparations: Should only be advised for women previously diagnosed with VVC who have a recurrence of the same symptoms 1
• Fluconazole precautions: Use with caution in patients with renal dysfunction or conditions that may predispose to arrhythmias 2

Clinical Pearls and Pitfalls

• Identifying Candida by culture in asymptomatic women should not lead to treatment, as 10-20% of women normally harbor Candida species in the vagina 1
• Women whose symptoms persist after using OTC preparations or who experience recurrence within 2 months should seek medical care 1
• Patients with a history of recurrent vaginitis are significantly less likely to respond to treatment 4
• The convenience of single-dose oral fluconazole should be weighed against the slightly higher incidence of drug-related adverse events compared to intravaginal agents 2
• Common side effects of oral fluconazole include mild gastrointestinal symptoms that are generally transient 3