What is the recommended treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

Uncomplicated Vaginal Candidiasis

For uncomplicated vaginal candidiasis, 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

Oral Therapy (Most Convenient)

• Fluconazole 150 mg orally as a single dose is the most convenient first-line option with excellent patient compliance and 80-90% clinical cure rates 1, 2
• This is FDA-approved for vaginal candidiasis and generally well-tolerated, with headache (13%), nausea (7%), and abdominal pain (6%) being the most common side effects 2

Topical Therapy (Equally Effective)

• Short-course regimens (1-3 days) are appropriate for mild-to-moderate uncomplicated infection 3, 1
• Topical azole options include:
  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
  • Miconazole 2% cream 5g intravaginally for 7 days 3
  • Terconazole 0.8% cream 5g intravaginally for 3 days 3, 4
  • Butoconazole 2% cream 5g intravaginally for 3 days 3
• All topical azoles are more effective than nystatin (80-90% vs lower cure rates) 1

Diagnostic Confirmation Required

• Always confirm diagnosis before treatment with wet-mount preparation using saline and 10% KOH to demonstrate yeasts or pseudohyphae 3, 5
• Check vaginal pH (should be ≤4.5 for VVC) 3, 5
• Obtain vaginal cultures if microscopy is negative but symptoms persist 3, 1

Complicated/Severe Vaginal Candidiasis

For severe infection or first episode with marked symptoms, use longer duration therapy: either topical azoles for 7-14 days OR fluconazole 150 mg orally every 72 hours for a total of 2-3 doses. 3, 5, 1

• Reserve 7-day topical regimens for severe symptoms 1
• The multi-dose fluconazole regimen (150 mg every 72 hours × 2-3 doses) is specifically for complicated cases 3, 5

Recurrent Vulvovaginal Candidiasis (RVVC)

For recurrent VVC (≥4 episodes per year), use induction therapy with topical azole or oral fluconazole for 10-14 days, followed by maintenance fluconazole 150 mg weekly for 6 months. 3, 5, 1

Induction Phase

• Treat for 10-14 days with either topical azole or oral fluconazole 3, 1

Maintenance Phase

• Fluconazole 150 mg once weekly for at least 6 months achieves >90% symptom control during maintenance 3, 1
• This regimen improves quality of life in 96% of women 3
• Be aware that recurrence occurs in >63% of women after completing maintenance therapy 3

Non-Albicans Candida Species (C. glabrata)

For C. glabrata infection, first-line treatment is nystatin intravaginal suppositories 100,000 units daily for 14 days. 3, 5

Alternative Options for C. glabrata

• Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 5
• Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 3, 5
• Note: Azole therapy, including voriconazole, is frequently unsuccessful for C. glabrata 3
• Important caveat: C. glabrata shows significantly reduced susceptibility to azoles at vaginal pH 4, with terconazole showing >388-fold higher MIC at pH 4 versus pH 7 3

Critical Clinical Pitfalls to Avoid

• Do NOT treat asymptomatic colonization - 10-20% of women harbor Candida without symptoms 3, 1
• Do NOT assume all vaginal symptoms are candidiasis - symptoms are nonspecific and can represent other etiologies 1
• Do NOT advise over-the-counter self-treatment unless the patient has been previously diagnosed with VVC and recognizes identical symptoms 3, 1
• Warn patients that oil-based creams and suppositories may weaken latex condoms and diaphragms 1
• Sexual partners do NOT require routine treatment unless symptomatic 1

Special Populations

Pregnancy

• Use ONLY topical azole therapy in pregnancy - fluconazole is contraindicated 3
• Fluconazole use during pregnancy has been associated with spontaneous abortion 3

HIV Infection

• Treatment should NOT differ based on HIV status - identical response rates are expected for HIV-positive and HIV-negative women 3, 5

Follow-Up Instructions

• Instruct patients to return only if symptoms persist after treatment or recur within 2 months 1
• If symptoms persist or recur quickly, obtain vaginal culture to identify non-albicans species 1