What is the recommended treatment for a 23-year-old female (YOF) with vaginal candidiasis?

Treatment of Vaginal Candidiasis in a 23-Year-Old Female

For uncomplicated vaginal candidiasis in this patient, treat with either oral fluconazole 150 mg as a single dose OR a short-course topical azole (1-3 days), both achieving >90% cure rates. 1

First-Line Treatment Options

Oral Therapy (Most Convenient)

• Fluconazole 150 mg oral tablet as a single dose 1
• Achieves 80-90% clinical cure and mycologic eradication rates 1, 2
• Most convenient option with excellent patient compliance 1

Topical Therapy (Equally Effective)

Multiple intravaginal azole options are available, all with equivalent efficacy 1:

Short-course regimens (1-3 days):

• Clotrimazole 500 mg vaginal tablet, single application 1
• Miconazole 200 mg suppository for 3 days 1
• Terconazole 0.8% cream 5g for 3 days 1
• Tioconazole 6.5% ointment 5g, single application 1

Standard regimens (7 days):

• Clotrimazole 1% cream 5g for 7 days 1
• Miconazole 2% cream 5g for 7 days 1

Key Clinical Considerations

Diagnosis Confirmation

Before treating, confirm the diagnosis with: 1

• Wet mount preparation (saline and 10% KOH) showing yeasts or pseudohyphae
• Normal vaginal pH (≤4.5) 1
• If microscopy is negative but symptoms persist, obtain vaginal culture 1

When to Use Longer Therapy

Reserve 7-day regimens for: 1

• Severe symptoms (extensive vulvar erythema, edema, excoriation, fissures) 1
• First episode with marked symptoms 1

Important Caveats

• Topical azoles are more effective than nystatin (80-90% vs lower cure rates) 1
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 1
• Most common side effects with fluconazole include headache (13%), nausea (7%), and abdominal pain (6%) 2
• Sexual partners do NOT require routine treatment unless symptomatic 1

Follow-Up and Recurrence

When to Return

Instruct the patient to return only if: 1

• Symptoms persist after treatment
• Symptoms recur within 2 months 1

If Treatment Fails or Recurs

If symptoms persist or recur quickly: 1

• Obtain vaginal culture to identify non-albicans species (C. glabrata, C. krusei)
• Consider complicated VVC requiring longer therapy (5-7 days topical OR fluconazole 150 mg every 72 hours for 3 doses) 1

Recurrent VVC (≥4 Episodes/Year)

If this develops (affects <5% of women): 1

• Induction: topical azole or oral fluconazole for 10-14 days 1
• Maintenance: fluconazole 150 mg once weekly for 6 months 1
• Achieves >90% symptom control during maintenance 1
• Expect 40-50% recurrence after stopping maintenance 1

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization - 10-20% of women harbor Candida without symptoms 1
• Do not advise OTC self-treatment unless the patient has been previously diagnosed with VVC and recognizes identical symptoms 1
• Do not assume all vaginal symptoms are candidiasis - symptoms are nonspecific and can represent other etiologies 1