What is the treatment for vaginal yeast infections?

Treatment for Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, either a single 150 mg oral dose of fluconazole or any topical azole antifungal agent (no agent superior to another) are equally effective first-line treatments, with oral fluconazole offering superior convenience and patient preference. 1

First-Line Treatment Options

Oral Therapy (Preferred for Convenience)

• Fluconazole 150 mg as a single oral dose is the most convenient option with 80-90% clinical and mycological cure rates 1, 2
• Achieves therapeutic vaginal concentrations rapidly and maintains them sufficiently for treatment 3
• Symptoms resolve more rapidly compared to intravaginal agents 4
• FDA-approved specifically for vaginal yeast infections 2

Topical Intravaginal Therapy (Equally Effective)

Multiple azole formulations are available with equivalent efficacy 1:

• Short-course options (1-3 days): Clotrimazole 500 mg single tablet, Miconazole 200 mg suppository for 3 days, Terconazole 0.8% cream for 3 days 1
• Standard course (7 days): Clotrimazole 1% cream, Miconazole 2% cream, Terconazole 0.4% cream 1
• Many preparations (butoconazole, clotrimazole, miconazole, tioconazole) are available over-the-counter 1

Important caveat: Topical azoles are more effective than nystatin, which requires 14 days of treatment 1

Treatment Based on Disease Severity

Severe Acute Vulvovaginitis

Fluconazole 150 mg every 72 hours for 2-3 total doses (strong recommendation for extensive vulvar erythema, edema, excoriation, fissures) 1

Complicated Vulvovaginal Candidiasis

For severe, recurrent, or infections in abnormal hosts (uncontrolled diabetes, immunosuppression) 1:

• Topical azole therapy for 5-7 days intravaginally, OR
• Fluconazole 150 mg every 72 hours for 3 doses 1

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

Two-phase approach 1:

1. Induction phase: 10-14 days of topical azole OR oral fluconazole
2. Maintenance phase: Fluconazole 150 mg once weekly for 6 months (achieves >90% symptom control) 1

Critical warning: 40-50% recurrence rate after stopping maintenance therapy 1

Species-Specific Treatment

C. glabrata Infections (Azole-Resistant)

When unresponsive to oral azoles 1:

1. First-line: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days (strong recommendation, ~70% cure rate) 1
2. Second-line: Nystatin 100,000 units intravaginal suppository daily for 14 days 1
3. Third-line: Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

Key distinction: Must determine if C. glabrata represents true infection versus colonization before treating 1

Special Populations

Pregnancy

Only topical azole therapy for 7 days (oral fluconazole contraindicated for routine use) 1, 5

HIV-Infected Women

Same treatment regimens as HIV-negative women with identical expected response rates 1

Breastfeeding

Fluconazole passes into breast milk; discuss risks/benefits with patient 2

Important Clinical Considerations

Diagnostic Confirmation Required

• Wet mount with 10% KOH showing yeasts/pseudohyphae, OR positive culture 1
• Normal vaginal pH (≤4.5) 1
• Do not treat asymptomatic colonization (10-20% of women harbor Candida normally) 1

Contraindications to Fluconazole

• Concomitant use with quinidine, erythromycin, or pimozide (QT prolongation risk) 2
• Patients with hypokalemia or advanced cardiac failure (increased arrhythmia risk) 2
• Known hypersensitivity to fluconazole 2

Partner Treatment

Not routinely recommended as vaginal candidiasis is not sexually transmitted 1

Self-Treatment Guidance

OTC preparations appropriate only for women with previously diagnosed VVC experiencing identical recurrent symptoms 1. Seek medical care if symptoms persist after OTC treatment or recur within 2 months 1.