Itraconazole for Fungal Vulvovaginitis
Itraconazole is not a first-line agent for vulvovaginal candidiasis; topical azoles or oral fluconazole are preferred for acute uncomplicated disease. However, when itraconazole is used, the recommended dose is 200 mg twice daily for 1 day (total 400 mg in one day) for acute vulvovaginal candidiasis 1.
Dosing Regimens for Acute Vulvovaginal Candidiasis
For acute sporadic vulvovaginal candidiasis, the evidence supports:
- 1-day regimen: 200 mg twice daily (400 mg total) in a single day 2, 3
- 3-day regimen: 200 mg once daily for 3 consecutive days 2, 4, 5
Both regimens demonstrate high efficacy, with cure rates of approximately 96-97% for acute sporadic disease 2, 3. The 1-day regimen (200 mg BID for 1 day) is as effective as the 3-day regimen for uncomplicated cases 2, 3.
Important Clinical Context
The CDC guidelines do not list itraconazole as a recommended first-line agent for vulvovaginal candidiasis 1. The recommended oral agent is fluconazole 150 mg as a single dose 1. Itraconazole is mentioned only as an alternative agent that "might be as effective as topical agents" but with consideration for potential toxicity 1.
Recurrent Vulvovaginal Candidiasis
For recurrent vulvovaginal candidiasis (≥4 episodes per year), the approach differs:
- Initial treatment: 200 mg twice daily for 1 day, or 200 mg daily for 3 days 2, 5
- Maintenance therapy: 200 mg once monthly (on the first day of menstrual cycle) for 6 months 6, 5
- Alternative maintenance: 400 mg once monthly or 100 mg once daily 1
The cure rates for recurrent disease are lower (approximately 77%) compared to acute sporadic disease, with relapses more common 2. Maintenance therapy for 6 months shows success rates of 64-85% in preventing recurrences 6, 5.
Critical Caveats
Monitoring serum itraconazole levels is recommended when used for systemic fungal infections to ensure adequate drug exposure, though this is typically not done for vulvovaginal candidiasis 1.
Drug interactions are significant: Itraconazole interacts with multiple medications including calcium channel blockers, protease inhibitors, oral hypoglycemics, and many others 1. Review the patient's medication list carefully before prescribing.
Hepatotoxicity risk: While less than ketoconazole, systemic azoles carry a risk of liver enzyme abnormalities 1. Ketoconazole specifically has hepatotoxicity rates of 1:10,000-15,000 exposed persons 1.
Pregnancy is an absolute contraindication to oral azoles including itraconazole; only topical azole therapy for 7 days should be used in pregnant women 1.
Practical Algorithm
For uncomplicated acute vulvovaginal candidiasis:
- First choice: Topical azole (3-7 days) or fluconazole 150 mg single dose 1
- If itraconazole is chosen: 200 mg twice daily for 1 day 2, 3
For complicated or recurrent disease:
- Initial treatment: 200 mg daily for 3 days 2, 5
- Followed by maintenance: 200 mg monthly for 6 months 6, 5
The discrepancy between severe symptoms and milder clinical signs is more common in recurrent disease than acute sporadic disease, which can complicate clinical assessment 2.