What is the treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

For uncomplicated vaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days), as both achieve >90% efficacy and are equally effective first-line options. 1

Diagnostic Confirmation Before Treatment

• Confirm diagnosis objectively before initiating therapy, as self-diagnosis is unreliable and less than half of patients clinically treated for VVC actually have the infection. 1
• Perform wet-mount preparation with saline and 10% potassium hydroxide to visualize yeast or pseudohyphae, and verify normal vaginal pH (4.0-4.5). 1
• Order vaginal cultures for patients with negative microscopy findings but persistent symptoms consistent with VVC. 1
• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida species in the vagina without infection. 2

Classification: Uncomplicated vs. Complicated

Uncomplicated VVC (90% of cases) includes mild-to-moderate symptoms, sporadic or infrequent episodes, likely Candida albicans, and immunocompetent hosts. 1

Complicated VVC (10% of cases) includes severe symptoms, recurrent episodes (≥4 per year), non-albicans species, or abnormal hosts (diabetes, immunosuppression, pregnancy). 1

First-Line Treatment for Uncomplicated VVC

Oral Therapy Option

• Fluconazole 150 mg orally as a single dose achieves 55% therapeutic cure (complete symptom resolution plus negative culture) and 69% clinical cure at one month. 3
• This regimen is as effective as 7-day intravaginal azole therapy but causes more gastrointestinal side effects (16% vs 4%), primarily mild-to-moderate nausea and abdominal pain. 3

Topical Therapy Options (Over-the-Counter)

• Clotrimazole 1% cream 5 g intravaginally daily for 7-14 days 2
• Miconazole 2% cream 5 g intravaginally daily for 7 days 2
• Miconazole 200 mg vaginal suppository daily for 3 days 2
• Tioconazole 6.5% ointment 5 g intravaginally as single application 2

Topical Therapy Options (Prescription)

• Terconazole 0.4% cream 5 g intravaginally daily for 7 days 2
• Terconazole 0.8% cream 5 g intravaginally daily for 3 days 2
• Butoconazole 2% cream 5 g intravaginally as single application (bioadhesive formulation) 2

Topically applied azole drugs are more effective than nystatin, achieving 80-90% symptom relief and negative cultures after therapy completion. 2

Treatment for Complicated VVC

Severe or Recurrent Disease

• For severe VVC, use 7-14 day regimens of topical azoles rather than single-dose treatments, as multi-day regimens are preferred for complicated cases. 2, 1
• For recurrent VVC (≥4 episodes per year), implement a two-phase approach: 1
  • Induction phase: 10-14 days of topical azole therapy OR fluconazole 150 mg every 72 hours for 2-3 doses 1
  • Maintenance phase: Fluconazole 150 mg orally weekly for 6 months, which achieves symptom control in >90% of patients 1
• Anticipate 40-50% recurrence rate after cessation of maintenance therapy, requiring possible reinitiation of suppressive treatment. 1

Non-Albicans Species

• For non-albicans Candida species (particularly C. glabrata), use boric acid 600 mg in gelatin capsule intravaginally daily for 14 days as first-line therapy, as these species are less responsive to standard azole therapy. 1
• Consider longer courses (7-14 days) of topical azoles if boric acid is unavailable. 1

Special Populations

Pregnancy

• Avoid oral fluconazole in pregnancy due to association with spontaneous abortion and congenital malformations; instead, use topical azole therapy for 7 days only. 1
• Metronidazole (for trichomoniasis, not VVC) is contraindicated in first trimester but may be used after first trimester. 2

HIV Infection

• Treatment should not differ based on HIV status, with identical response rates expected for HIV-positive and HIV-negative women. 1
• HIV-infected patients report adverse events more frequently (21% vs 13%) but have similar discontinuation rates and treatment efficacy. 3

Common Pitfalls and Caveats

• Single-dose treatments should be reserved for uncomplicated mild-to-moderate VVC only; patients with severe symptoms, recurrent disease, or complicated VVC require extended therapy. 2
• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with VVC who experience recurrence of identical symptoms. 2
• Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses. 2
• VVC may be present concurrently with sexually transmitted diseases, so maintain appropriate clinical suspicion and testing. 2

Adverse Effects

Oral Fluconazole

• Most common side effects include headache (13%), nausea (7%), and abdominal pain (6%) with single-dose therapy. 3
• Rare but serious hepatic reactions ranging from transient transaminase elevations to fulminant hepatic failure have been reported, primarily in patients with serious underlying conditions. 3
• Drug interactions occur with astemizole, calcium channel antagonists, cisapride, warfarin, and protease inhibitors. 1

Topical Azoles

• Local burning or irritation may occur but systemic side effects are rare. 1
• Terconazole most frequently causes headache (26%), vulvovaginal itching (leading cause of discontinuation), and body pain. 4