What is the treatment for vulva candidiasis?

Treatment of Vulvovaginal Candidiasis

For uncomplicated vulvovaginal candidiasis, use either a single 150 mg oral dose of fluconazole or topical azole therapy for 1-7 days, as both achieve >90% clinical response rates. 1, 2

Uncomplicated Vulvovaginal Candidiasis

First-line treatment options (choose one):

• Oral fluconazole 150 mg as a single dose 1, 2, 3
• Topical azole therapy (clotrimazole, miconazole, terconazole) for 1-7 days 1, 4

Both routes are therapeutically equivalent with cure rates exceeding 90% in immunocompetent women with Candida albicans infection. 1, 3 The single-dose oral fluconazole regimen offers convenience and high patient preference, though topical therapy may be preferred in certain situations. 4, 5

Complicated Vulvovaginal Candidiasis

Complicated cases include: severe symptoms, recurrent disease (≥4 episodes/year), non-albicans species, immunocompromised hosts, uncontrolled diabetes, or pregnancy. 1

Treatment approach:

• Fluconazole 150 mg every 72 hours for 3 doses (total 450 mg over 6 days) 1, 2
• Alternative: Topical azole therapy for 7-14 days 1, 2

For severe acute vulvovaginal candidiasis specifically, the Infectious Diseases Society of America recommends fluconazole 150 mg every 72 hours for 2-3 doses. 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

Induction phase:

• Fluconazole 150 mg every 72 hours for 3 doses OR topical azole for 10-14 days 2, 6

Maintenance phase:

• Fluconazole 150 mg weekly for 6 months 2, 6

This maintenance regimen improves quality of life in 96% of women, though recurrence after discontinuation occurs in >63% of cases. 7 Longer maintenance courses are recommended for documented multiple recurrences. 6

Non-Albicans Species (particularly C. glabrata)

When standard azole therapy fails, consider non-albicans species and use: 1, 2

• Intravaginal boric acid 600 mg daily for 14 days
• Nystatin intravaginal suppositories
• 17% flucytosine cream alone or combined with 3% amphotericin B cream

The reduced susceptibility of C. glabrata at vaginal pH 4 (particularly to terconazole, with >388-fold higher MIC) explains many treatment failures. 7

Special Populations

Pregnancy:

• Use ONLY topical azole therapy for 7 days 7, 5
• Oral fluconazole is contraindicated due to association with spontaneous abortion 7
• Treatment of symptomatic infection in pregnancy is warranted 6

HIV-positive women:

• Treatment regimens are identical to HIV-negative women with equivalent response rates expected 1

Critical Diagnostic Considerations

Confirm diagnosis before treatment: 2

• Wet mount with 10% KOH to visualize yeast/pseudohyphae
• Vaginal pH ≤4.5 (higher pH suggests bacterial vaginosis or trichomoniasis)
• Vaginal culture if wet mount negative but symptoms persist

Symptoms (pruritus, discharge, dysuria, dyspareunia) are nonspecific and can result from multiple infectious and non-infectious causes. 2 Laboratory confirmation is essential, especially for recurrent cases. 1

Common Pitfalls to Avoid

Do not treat asymptomatic colonization: 10-20% of women harbor Candida species without symptoms; treatment is not indicated. 2

Recognize treatment failure patterns: If symptoms persist after treatment or recur within 2 months, obtain repeat cultures to identify non-albicans species requiring alternative therapy. 2

Avoid alternative/complementary therapies: Honey-based ointments, essential oils (tea tree, lavender, oregano), and ginger-clotrimazole combinations show equal or inferior results to FDA-approved medications and lack regulation. 7

Adequate treatment duration matters: Complicated cases require longer courses than uncomplicated infections; insufficient duration leads to treatment failure. 1

Adverse Effects

The most common side effects with single-dose fluconazole 150 mg include headache (13%), nausea (7%), and abdominal pain (6%). 3 Most adverse events are mild to moderate. 3 Rare cases of serious hepatic reactions and anaphylaxis have been reported, though these occur primarily in patients with serious underlying conditions taking multiple concomitant medications. 3

Follow-Up

Clinical cure or improvement should be evident within 5-16 days. 2 Test of cure is not routinely needed for uncomplicated cases, but re-evaluation with repeat cultures is required if symptoms persist or recur within 2 months. 2