What is the recommended treatment for vulvovaginal candidiasis in elderly patients?

Treatment of Vulvovaginal Candidiasis in Elderly Patients

For elderly patients with vulvovaginal candidiasis, both topical azole formulations (for 3-7 days) and oral fluconazole 150 mg as a single dose are equally effective first-line treatments, with both achieving >90% response rates. 1, 2

Diagnosis Confirmation

• Before initiating treatment, diagnosis should be confirmed through wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1, 3
• Vaginal pH should be checked (normal is 4.0-4.5) 1, 3
• For negative microscopy findings, vaginal cultures should be obtained 1

Treatment Options Based on Severity

Uncomplicated VVC (mild-to-moderate)

• Topical options (all equally effective):

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

• Oral option:

  • Fluconazole 150 mg oral tablet, single dose 1, 4

Complicated VVC (severe)

• Fluconazole 150 mg every 72 hours for a total of 2-3 doses 1, 2
• OR topical azole therapy for 7-14 days 1, 2

Special Considerations for Elderly Patients

• Topical formulations may be preferable in elderly patients with multiple medications to avoid potential drug interactions with oral fluconazole 4
• Elderly patients may have difficulty with vaginal applicators; consider alternative formulations such as suppositories or tablets if dexterity is limited 5
• For elderly patients with recurrent infections, maintenance therapy with fluconazole 150 mg weekly for 6 months may be necessary 1, 2
• After cessation of maintenance therapy, a 40-50% recurrence rate can be anticipated 1

Non-albicans Candida Species

• For suspected non-albicans species (particularly C. glabrata), which are often resistant to azoles:
  • Boric acid 600 mg in gelatin capsule vaginally daily for 14 days 1
  • Nystatin intravaginal suppositories 100,000 units daily for 14 days 1, 6
  • Topical 17% flucytosine cream alone or with 3% AmB cream for 14 days 1

Potential Adverse Effects

• Topical agents rarely cause systemic side effects but may cause local burning or irritation 2, 4
• Oral fluconazole may cause nausea (7%), abdominal pain (6%), headache (13%), and diarrhea (3%) 4
• Fluconazole may interact with several medications including calcium channel antagonists, coumadin, and protease inhibitors, which is an important consideration in elderly patients who often take multiple medications 2, 4

Follow-up

• If symptoms persist after treatment, reevaluation with culture is recommended to confirm the diagnosis and identify potential resistant species 1, 7
• For recurrent vulvovaginal candidiasis (≥4 episodes/year), consider maintenance therapy with fluconazole 150 mg weekly for 6 months 1, 8