What is the treatment for vaginal candidosis?

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, 2

Classification Determines Treatment Approach

Before initiating therapy, classify the infection as either uncomplicated (90% of cases) or complicated (10% of cases), as this fundamentally changes treatment duration and strategy. 1

Uncomplicated VVC is defined as:

• Sporadic or infrequent episodes (<4 per year)
• Mild to moderate symptoms
• Likely caused by Candida albicans
• Occurring in immunocompetent, non-pregnant women 3

Complicated VVC includes:

• Recurrent infections (≥4 episodes per year)
• Severe symptoms
• Non-albicans Candida species
• Pregnancy, uncontrolled diabetes, immunosuppression, or HIV infection 3, 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 in controlled trials 2
• This regimen is convenient and equally effective as 7-day topical therapy 1, 2

Topical Therapy Options

Multiple azole formulations are available and equally effective, achieving 80-90% symptom relief: 3, 1

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 3, 1
• Miconazole 2% cream 5g intravaginally daily for 7 days 3, 1
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 3, 1
• Tioconazole 6.5% ointment 5g intravaginally as single application 3, 1

Important caveat: Topically applied azole drugs are more effective than nystatin and should be preferred. 3

Treatment for Complicated VVC

Severe or Recurrent Disease

• Fluconazole 150 mg every 72 hours for 2-3 doses OR topical azole therapy for 7-14 days (not the shorter 1-3 day regimens) 1
• Longer initial therapy duration is essential to achieve remission before considering maintenance therapy 3

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

A two-phase approach is required: 1

Induction Phase:

• 10-14 days of topical azole agent OR oral fluconazole to achieve initial control 1

Maintenance Phase:

• Fluconazole 150 mg orally weekly for 6 months achieves symptom control in >90% of patients during suppressive therapy 1
• After cessation of maintenance therapy, expect 40-50% recurrence rate 1

Non-Albicans Species

• Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days is first-line treatment for non-albicans species, which are less responsive to standard azole therapy 1
• For C. glabrata specifically, fluconazole 800 mg orally daily for 2-3 weeks may be required in some regions where boric acid is unavailable 4

Special Population Considerations

Pregnancy

• Avoid oral fluconazole completely due to association with spontaneous abortion and congenital malformations 1
• Use only 7-day topical azole therapy (not shorter regimens) 3, 1
• Topical clotrimazole in first trimester may reduce premature birth rates 4

HIV-Positive Patients

• Treatment regimens should be identical to HIV-negative women, with equivalent response rates expected 3, 1

Critical Diagnostic Considerations Before Treatment

• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida species without infection 3, 1
• Confirm diagnosis with wet-mount preparation using 10% KOH to visualize yeast or pseudohyphae, and verify normal vaginal pH (≤4.5) 3, 1
• Self-diagnosis is unreliable; microscopic confirmation should be obtained before treatment 1
• VVC may be present concurrently with sexually transmitted diseases, so maintain appropriate clinical suspicion 1

Common Pitfalls to Avoid

• Single-dose treatments (oral or topical) should be reserved exclusively for uncomplicated mild-to-moderate VVC; patients with severe symptoms, recurrent disease, or complicated VVC require extended therapy 1
• Any woman whose symptoms persist after over-the-counter treatment or who experiences recurrence within 2 months must seek medical evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses 1
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of identical symptoms 1

Adverse Effects Profile

Oral Fluconazole

• Most common side effects: headache (13%), nausea (7%), abdominal pain (6%), diarrhea (3%) 2
• Most events are mild to moderate in severity 2
• Drug interactions occur with astemizole, calcium channel antagonists, cisapride, warfarin, and protease inhibitors 1
• Rare cases of serious hepatic reactions have been reported, primarily in patients with serious underlying conditions 2

Topical Azoles

• May cause local burning or irritation but rarely cause systemic side effects 1
• Terconazole most frequently causes vulvovaginal itching leading to discontinuation 5
• Headache (26%) and body pain (2.1%) reported with terconazole cream 5

Treatment of Sex Partners

• VVC is not normally acquired through sexual intercourse 3
• Treatment of sex partners may be considered only in women who have recurrent infection 3