What is recommended for the treatment of vulvovaginal candidiasis?

Treatment of Vulvovaginal Candidiasis

For uncomplicated vulvovaginal candidiasis, treat with either topical azole antifungals (intravaginal for 1-7 days) or a single 150 mg oral dose of fluconazole, both achieving 80-90% cure rates. 1

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg as a single oral dose is highly effective for uncomplicated VVC, achieving therapeutic cure rates of 55% (complete symptom resolution plus negative culture) and clinical cure rates of 69% 2, 1
• Oral fluconazole offers convenience but causes more gastrointestinal side effects (16% vs 4% with vaginal products), including nausea (7%), abdominal pain (6%), and diarrhea (3%) 2

Topical Intravaginal Therapy

Over-the-counter options (no prescription required):

• Clotrimazole 1% cream 5g daily for 7-14 days 1
• Clotrimazole 2% cream 5g daily for 3 days 1
• Miconazole 2% cream 5g daily for 7 days 1
• Miconazole 4% cream 5g daily for 3 days 1
• Miconazole 100 mg suppository daily for 7 days 1
• Miconazole 200 mg suppository daily for 3 days 1
• Miconazole 1200 mg suppository as single dose 1
• Tioconazole 6.5% ointment 5g as single application 1

Prescription intravaginal options:

• Butoconazole 2% cream 5g as single application (bioadhesive formulation) 1
• Terconazole 0.4% cream 5g daily for 7 days 1
• Terconazole 0.8% cream 5g daily for 3 days 1
• Terconazole 80 mg suppository daily for 3 days 1

Treatment Selection Algorithm

For Uncomplicated VVC (mild-to-moderate, sporadic, first episode)

• Single-dose or short-course (1-3 day) regimens are appropriate 1
• Choose based on patient preference: oral fluconazole for convenience vs topical therapy to avoid systemic side effects 2
• Topical azoles achieve 80-90% symptom relief and negative cultures 1

For Complicated VVC (severe symptoms, recurrent disease, diabetes, immunocompromised)

• Use longer duration therapy: 7-14 day topical azole regimens 1
• Avoid single-dose treatments in these populations 1

For Pregnancy

• Use ONLY topical azole therapy; oral fluconazole is contraindicated 3, 1
• Recommend 7-day regimens as they are more effective than shorter courses during pregnancy 3
• Preferred options: Clotrimazole 1% cream for 7-14 days or Miconazole 2% cream for 7 days 3

For HIV-Infected Women

• Treat with the same regimens as HIV-negative women 1
• VVC may be more severe but responds to standard therapy 1

Important Clinical Considerations

Diagnosis Confirmation

• Do not treat based on symptoms alone—less than 50% of women self-diagnosing VVC actually have it 1
• Confirm diagnosis with wet mount showing yeast/pseudohyphae OR positive culture 1
• Vaginal pH remains ≤4.5 with Candida infection (unlike bacterial vaginosis or trichomoniasis) 1, 3
• 10% KOH preparation improves visualization of yeast forms 1

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization—10-20% of women harbor Candida without symptoms 1
• Do not routinely treat sexual partners as VVC is not sexually transmitted 1
• Only treat male partners if they have symptomatic balanitis (erythema and pruritus on glans) 1
• Patients should return only if symptoms persist or recur within 2 months 1

Self-Treatment Guidelines

• OTC self-treatment is appropriate ONLY for women with previously diagnosed VVC experiencing identical recurrent symptoms 1
• Any woman with persistent symptoms after OTC treatment or recurrence within 2 months must seek medical evaluation 1

Drug Resistance and Non-Albicans Species

• C. albicans causes 74% of cases and is usually azole-sensitive 4
• C. glabrata (20% of cases) may require longer treatment courses 4
• Consider culture and sensitivity testing for recurrent cases or treatment failures 5

Adverse Effects

• Topical agents: local burning or irritation (generally well-tolerated) 1
• Oral fluconazole: headache (13%), nausea (7%), abdominal pain (6%), rare hepatotoxicity 2
• Serious hepatic reactions with oral azoles are rare but can be fatal, particularly in patients with AIDS or malignancy taking multiple medications 2