What is the treatment for vulvar vaginitis?

Treatment of Vulvar Vaginitis

For vulvovaginal candidiasis (VVC), the recommended first-line treatment is either topical azole formulations (1-3 days) or single-dose oral fluconazole (150 mg), which have 80-90% success rates. 1

Vulvovaginal Candidiasis (VVC) Treatment

Uncomplicated VVC

• Topical options (all equally effective):

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

• Oral option:

  • Fluconazole 150mg oral tablet, single dose 2, 1

Complicated VVC

Severe VVC

• Extended topical azole therapy (7-14 days) or fluconazole 150mg oral dose repeated after 72 hours 2, 1

Recurrent VVC (4+ episodes per year)

• Initial therapy: Longer duration treatment (7-14 days topical or fluconazole 150mg oral repeated after 3 days) 2, 1
• Maintenance therapy (continue for 6 months):
  • Fluconazole 100-150mg weekly 2, 1
  • Clotrimazole 500mg vaginal suppositories weekly 2, 1
  • Ketoconazole 100mg daily (monitor for hepatotoxicity) 2
  • Itraconazole 400mg monthly or 100mg daily 2

Non-albicans VVC

• Longer duration (7-14 days) with non-fluconazole azole drugs 1
• For persistent recurrence: nystatin 100,000 units daily via vaginal suppositories 1

Bacterial Vaginosis (BV) Treatment

Standard Regimen

• Metronidazole 500mg orally twice daily for 7 days 2
  • Note: Patients should avoid alcohol during treatment and for 24 hours after 2

Alternative Regimens

• Metronidazole 2g orally in a single dose 2
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 2
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally, twice daily for 5 days 2
• Clindamycin 300mg orally twice daily for 7 days 2

Trichomoniasis Treatment

• Standard treatment: Metronidazole 2g orally in a single dose 3, 4
• Alternative: Metronidazole 500mg twice daily for 7 days (recommended for persistent cases) 5, 3
• Sex partners should also be treated 3, 4

Special Considerations

Pregnancy

• For VVC: Only topical azole therapies for 7 days 1
• For BV: Clindamycin vaginal cream during first trimester; oral metronidazole can be used during second and third trimesters 2

HIV Infection

• Same treatment regimens as HIV-negative patients 2

Compromised Hosts

• Extended 7-14 day treatment course 1

Follow-Up and Management

• Patients should return only if symptoms persist or recur within 2 months 2, 1
• For recurrent VVC, obtain vaginal cultures to confirm diagnosis and identify unusual species 2, 1
• Treatment of sex partners is generally not recommended for VVC but may be considered for recurrent cases 2, 1
• For BV and trichomoniasis, treatment of sex partners is recommended 2, 3

Common Pitfalls and Caveats

• OTC preparations should only be used by women previously diagnosed with VVC experiencing recurrent symptoms 2, 1
• Inappropriate self-treatment can delay proper diagnosis of other causes of vulvovaginitis 1
• Azole creams and suppositories may weaken latex condoms and diaphragms 2, 1
• If symptoms persist despite appropriate treatment, consider alternative diagnoses such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia 5