What is the treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

For uncomplicated vaginal candidiasis (90% of cases), use either a single 150 mg oral dose of fluconazole or short-course topical azole therapy for 1-7 days, as both achieve >90% efficacy and are equally effective. 1, 2, 3

Classification: Uncomplicated vs. Complicated

Vaginal candidiasis must be classified before treatment, as this determines therapy duration and approach: 4, 1, 2

Uncomplicated (90% of cases): 4, 2

• Sporadic episodes in immunocompetent women 1
• Mild-to-moderate symptoms 1
• Candida albicans infection 1, 2
• Non-pregnant, non-immunocompromised host 1

Complicated (10% of cases): 4, 1, 2

• Severe symptoms (extensive vulvar erythema, edema, excoriation) 1
• Recurrent disease (≥4 episodes per year) 1, 2
• Non-albicans Candida species 4, 1
• Uncontrolled diabetes, immunosuppression, or pregnancy 1

Diagnostic Confirmation Required Before Treatment

Do not treat based on symptoms alone—self-diagnosis is unreliable and leads to overuse of antifungals with risk of contact dermatitis. 4, 1

Confirm diagnosis with: 2, 3

• Wet-mount preparation with 10% potassium hydroxide demonstrating yeast or hyphae 2, 3
• Vaginal pH 4.0-4.5 (higher pH suggests bacterial vaginosis or trichomoniasis) 1, 3
• Vaginal cultures for patients with negative microscopy but suspected infection 2, 3
• Do not treat asymptomatic colonization—10-20% of women harbor Candida without symptoms 3

Treatment Algorithm

Uncomplicated Vaginal Candidiasis

First-line options (choose one): 1, 2, 3

Oral therapy:

• Fluconazole 150 mg orally as single dose 4, 1, 2, 3, 5
• Achieves 55% therapeutic cure (clinical resolution + mycologic eradication) and 69% clinical cure at one month 5

Topical azole therapy (all equally effective): 4, 2, 3

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 2, 3
• Clotrimazole 100 mg vaginal tablet daily for 7 days 2, 3
• Miconazole 2% cream 5g intravaginally for 7 days 3
• Butoconazole 2% cream 5g intravaginally for 3 days 4, 3
• Tioconazole 6.5% ointment 5g intravaginally as single application 3
• Terconazole (various formulations for 3-7 days) 4

Alternative:

• Nystatin 100,000 U daily for 7-14 days 4, 3

Complicated Vaginal Candidiasis

Requires longer treatment duration—minimum 7-14 days rather than single-dose regimens. 1, 2, 3

For severe acute disease: 1, 3

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

For non-albicans species (C. glabrata and others): 4, 1, 2

• Azole therapy is unreliable for non-albicans species 4, 2
• First-line: Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 4, 1, 2, 3
• Alternative: Nystatin intravaginal suppositories 1, 3
• Refractory cases: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days 1, 3

Recurrent Vaginal Candidiasis (≥4 Episodes Per Year)

Use a two-phase approach: induction therapy followed by 6-month maintenance suppression. 4, 1, 2, 3

Induction phase (after controlling causal factors like uncontrolled diabetes): 4, 2, 3

• Topical azole for 10-14 days 4, 2, 3
• OR oral fluconazole for 10-14 days 2, 3

Maintenance phase for 6 months: 4, 1, 2, 3

• Fluconazole 150 mg orally weekly (preferred regimen) 4, 1, 2, 3
• Achieves symptom control in >90% of patients during maintenance 2, 3
• Improves quality of life in 96% of women 1, 3
• Alternative: Ketoconazole 100 mg daily, itraconazole 100 mg every other day, or daily topical azole 4, 3

Critical caveat: Expect 40-63% recurrence rate after stopping maintenance therapy—this is rarely curative. 1, 2, 3

Special Populations

Pregnancy

Fluconazole is contraindicated in pregnancy due to association with spontaneous abortion and congenital malformations. 1, 3

• Use topical azole therapy for 7 days only 1, 3
• Avoid all oral azoles throughout pregnancy 3

HIV-Positive Women

Treatment should not differ based on HIV status—identical response rates are expected for HIV-positive and HIV-negative women. 1, 2, 3

• Use same regimens as for HIV-negative women 2, 3
• Lower CD4+ counts are associated with increased VVC rates 3

Adverse Effects

Topical agents: 2

• Rarely cause systemic effects 2
• May cause local burning or irritation 2
• Application site reactions in 5% 5

Oral fluconazole: 2, 5

• Headache (13%), nausea (7%), abdominal pain (6%) 5
• Diarrhea (3%), dyspepsia (1%), dizziness (1%), taste perversion (1%) 5
• Gastrointestinal events substantially more common than with topical therapy (16% vs 4%) 5
• Rare serious hepatic reactions (transient transaminase elevations to fulminant hepatic failure) 5
• Drug interactions with astemizole, calcium channel antagonists, cisapride, warfarin, and protease inhibitors 2

Common Pitfalls to Avoid

• Do not treat without microscopic confirmation—symptoms are nonspecific and can be caused by bacterial vaginosis, trichomoniasis, or non-infectious etiologies 1, 2
• Do not use short-course therapy for complicated cases—requires minimum 7-14 days 1, 2, 3
• Do not use azoles for non-albicans species—switch to boric acid or alternative agents 4, 1, 2
• Do not use alternative/complementary therapies (honey-based ointments, essential oils)—these show equal or inferior results to FDA-approved medications and lack regulation 1
• Do not expect cure from maintenance therapy—counsel patients about high recurrence rates after discontinuation 1, 2, 3