What is the treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

Signs and Symptoms

Vaginal itching is the most specific symptom of vulvovaginal candidiasis, though patients may also experience vaginal soreness, swelling, dyspareunia, dysuria, or increased discharge. 1

Clinical Presentation

• Pruritus (itching) is the hallmark symptom and most specific to VVC 1
• Vaginal discharge may be present but is not always prominent 1
• Vulvar edema and erythema on physical examination 2
• Vaginal soreness and swelling 1
• Dyspareunia (painful intercourse) 1
• External dysuria (burning with urination) 1
• Normal vaginal pH (4.0-4.5) is characteristic—higher pH suggests bacterial vaginosis or trichomoniasis 3, 2

Diagnostic Confirmation

• Wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae is the standard diagnostic approach 3
• Vaginal cultures should be obtained for patients with negative microscopy findings but suspected infection 3
• Do not treat asymptomatic colonization—10-20% of women normally harbor Candida in the vagina without symptoms 3

---

Treatment Algorithm

Uncomplicated VVC (90% of cases)

For uncomplicated vulvovaginal candidiasis, either short-course topical azole therapy or a single 150 mg oral dose of fluconazole is recommended, with both approaches showing >90% efficacy. 1, 3, 2

Oral Option (Preferred for Convenience)

• Fluconazole 150 mg orally as a single dose 1, 3, 4
• Achieves 55% therapeutic cure rate (complete symptom resolution plus negative culture) 4
• Clinical cure rate of 69% at one-month follow-up 4

Topical Options (Multiple Regimens Available)

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
• Clotrimazole 100 mg vaginal tablet daily for 7 days 3
• Miconazole 2% cream 5g intravaginally for 7 days 1, 3
• Butoconazole 2% cream 5g intravaginally for 3 days 3
• Tioconazole 6.5% ointment 5g intravaginally as single application 3
• Nystatin 100,000 U daily for 7-14 days 1

All topical and oral azole regimens demonstrate equivalent efficacy for uncomplicated VVC. 1, 2

---

Complicated VVC (10% of cases)

Complicated VVC requires longer treatment courses—at least 7-14 days of therapy rather than single-dose regimens. 1, 3, 2

Severe Acute VVC

• Fluconazole 150 mg every 72 hours for 2-3 doses 3, 2
• Alternatively, topical azole therapy for 7-14 days 1, 5

Non-albicans Candida (especially C. glabrata)

For C. glabrata and other non-albicans species, azole therapy is unreliable and alternative agents are required. 1

• First-line: Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 1, 3, 2
• Alternative: Nystatin intravaginal suppositories 2
• Refractory cases: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days 1, 3, 2

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. 1

---

Recurrent VVC (≥3 episodes per year)

Recurrent VVC affects approximately 9% of women and requires a two-phase approach: induction therapy followed by maintenance suppression. 1

Induction Phase

• Topical azole for 10-14 days OR oral fluconazole for 10-14 days 3, 2

Maintenance Phase

• Fluconazole 150 mg orally weekly for 6 months 1, 3, 2, 6
• This regimen achieves symptom control in >90% of patients during maintenance 3, 6
• Alternative maintenance options include ketoconazole 100 mg daily, itraconazole 100 mg every other day, or daily topical azole 1

Expected Outcomes and Limitations

• At 6 months (end of maintenance): 90.8% remain disease-free 6
• At 12 months (6 months post-maintenance): only 42.9% remain disease-free 6
• Recurrence rate of 40-63% after stopping maintenance therapy is expected 1, 3, 2, 6
• Median time to recurrence: 10.2 months with fluconazole maintenance versus 4.0 months with placebo 6

Maintenance fluconazole improves quality of life in 96% of women but is rarely curative, with most women experiencing recurrence after discontinuation. 1, 2

Emerging Therapies for Recurrent VVC

• Oteseconazole (not yet commercially available) showed remarkably lower recurrence rates (4% vs 52% placebo) at 48 weeks in clinical trials 1

---

Special Populations

Pregnancy

Fluconazole is contraindicated during pregnancy, particularly in the first trimester, due to associations with spontaneous abortion and congenital malformations. 1, 2

• Use topical azole therapy for 7 days in pregnant women 2
• Oral azoles should be avoided throughout pregnancy 1, 2

HIV-Positive Women

Treatment of VVC should not differ based on HIV status—identical response rates are expected for HIV-positive and HIV-negative women. 3, 2

• Lower CD4+ T-cell counts are associated with increased rates of VVC 1
• VVC is associated with increased viral shedding 1
• Treatment regimens remain the same as for HIV-negative women 3, 2

---

Common Pitfalls and Caveats

Misdiagnosis

Symptoms of VVC are nonspecific and can be caused by various infectious and non-infectious etiologies—laboratory confirmation is essential, especially for recurrent cases. 2

• Self-diagnosis of yeast vaginitis is unreliable 1
• Incorrect diagnosis results in overuse of topical antifungals with subsequent risk of contact and irritant vulvar dermatitis 1

Over-the-Counter Preparations

OTC preparations should only be recommended for women previously diagnosed with VVC who experience recurrence of identical symptoms. 3

• Women whose symptoms persist after using OTC preparations or who experience recurrence within 2 months should seek medical care 3

Alternative Therapies

Alternative/complementary therapies such as honey-based ointments, essential oils, probiotics, and vitamin C show equal or inferior results to FDA-approved medications and lack regulation. 2, 5

• No evidence supports the use of probiotics for VVC treatment 1, 5

Azole Resistance

Azole-resistant C. albicans infections are extremely rare but can occur after prolonged azole exposure. 1, 3

• No evidence of fluconazole resistance developed in long-term maintenance studies 6
• No superinfection with C. glabrata occurred during fluconazole maintenance therapy 6

Adverse Effects

Most common side effects with single-dose fluconazole 150 mg include headache (13%), nausea (7%), and abdominal pain (6%). 4

• Substantially more gastrointestinal events occur with oral fluconazole compared to vaginal products 4
• Rare cases of serious hepatic reactions have been reported, primarily in patients with serious underlying conditions 4
• Fluconazole was discontinued in only 1.5% of patients due to adverse events in clinical trials 4

Follow-up

For uncomplicated infections with symptom resolution, follow-up is generally unnecessary. 3

• Test of cure is not routinely recommended for uncomplicated VVC 3