For vaginal candidiasis, should I prescribe a vaginal suppository or oral medication?

Treatment Choice for Vaginal Candidiasis

For uncomplicated vaginal candidiasis, either a single 150 mg oral dose of fluconazole or topical intravaginal azole therapy (such as miconazole 2% cream for 7 days or terconazole suppositories for 3 days) are equally effective first-line options, with both achieving >80-90% cure rates. 1, 2, 3

Decision Algorithm

Choose Oral Fluconazole 150 mg single dose if:

• Patient prefers oral administration over vaginal application 4, 5
• Patient compliance is a concern (single dose ensures completion) 1
• Patient has uncomplicated, mild-to-moderate symptoms 1, 3
• Patient is not pregnant or breastfeeding 6, 4

Choose Vaginal Suppository/Cream if:

• Patient is pregnant (only topical azoles are safe; use 7-day regimen) 1, 3
• Patient is breastfeeding 4
• Patient has severe vulvovaginitis with extensive erythema, edema, or fissures (requires 7-14 days of topical therapy) 1
• Patient prefers to avoid systemic medication 1
• Cost is a primary concern (topical agents are generally less expensive) 5

Specific Regimen Options

Oral Option:

• Fluconazole 150 mg as a single oral dose 1, 6, 5

Topical Options (equally effective):

• Miconazole 2% cream 5g intravaginally daily for 7 days (available OTC) 1, 2
• Terconazole 0.8% cream 5g intravaginally daily for 3 days 1
• Terconazole 80 mg suppository daily for 3 days 1, 7
• Clotrimazole 2% cream 5g intravaginally daily for 3 days 1

Critical Caveats

Pregnancy is an absolute contraindication to oral fluconazole due to association with spontaneous abortion; only 7-day topical azole therapy should be used. 1, 3, 6

Warn patients using oil-based vaginal creams (like miconazole) that these may weaken latex condoms and diaphragms. 2

Reserve self-treatment with OTC preparations only for women previously diagnosed with VVC who experience identical recurrent symptoms. 1, 2

Instruct patients to return if symptoms persist after treatment or recur within 2 months, as this may indicate complicated VVC, non-albicans species, or misdiagnosis. 1, 2, 3

When Standard Therapy May Fail

If the patient has severe vulvovaginitis (extensive vulvar erythema, edema, excoriation, fissures), use either:

• 7-14 days of topical azole therapy, OR
• Fluconazole 150 mg repeated 72 hours later (two doses total) 1, 3

If symptoms recur despite appropriate treatment, consider:

• Non-albicans Candida species (requires culture and longer therapy with non-fluconazole azoles) 1, 3
• Recurrent VVC (≥3 episodes/year requires maintenance therapy) 1
• Alternative diagnosis (bacterial vaginosis, trichomoniasis, dermatologic conditions) 3