What is the treatment for a vulvar infection?

Treatment of Vulvar Infection

For vulvar infections, initiate treatment with topical azole antifungals (clotrimazole 1% cream or miconazole 2% cream) applied to the affected vulvar area for 7-14 days, or alternatively use oral fluconazole 150 mg as a single dose for uncomplicated cases. 1

Diagnostic Approach

Before treating, confirm the diagnosis by identifying the specific etiology:

• Vulvovaginal candidiasis (VVC) presents with vulvar pruritus, burning, erythema, and possibly white discharge with normal vaginal pH (<4.5) 1, 2
• Diagnosis is confirmed by wet preparation or Gram stain showing yeasts/pseudohyphae, or positive culture for yeast species 3, 2
• Trichomoniasis presents with vulvar irritation and yellow-green malodorous discharge 1
• Consider bacterial vaginosis, contact dermatitis, or other dermatologic conditions if presentation differs 4, 5

First-Line Treatment Options

For Uncomplicated Vulvovaginal Candidiasis

Topical azole therapy (choose one):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 2
• Miconazole 2% cream applied to vulvar area for 7-14 days 1
• Butoconazole 2% cream 5g intravaginally for 3 days 2

Oral therapy (alternative):

• Fluconazole 150 mg as a single oral dose 1, 2

Both topical and oral azole therapies achieve 80-90% cure rates in uncomplicated cases 1, 3

For Trichomoniasis with Vulvar Involvement

• Metronidazole oral therapy is required (not topical treatment) 1, 6
• Treat sexual partners simultaneously to prevent reinfection 1, 6

Treatment Selection Algorithm

Mild to moderate vulvar symptoms:

• Start with topical azole (clotrimazole 1% or miconazole 2%) for 7-14 days 1
• Single-dose oral fluconazole is equally effective for patient convenience 1, 2

Severe vulvovaginitis (extensive vulvar erythema, edema, excoriation, fissures):

• Use 7-14 days of topical azole therapy (short courses have lower response rates) 1
• Alternatively, fluconazole 150 mg repeated after 3 days 1

Recurrent infections (≥4 episodes per year):

• Initial treatment: 7-14 days topical azole OR fluconazole 150 mg repeated 3 days later 1
• Followed by maintenance therapy for 6 months with weekly fluconazole 100-150 mg OR daily ketoconazole 100 mg OR weekly clotrimazole 500 mg suppositories 1
• Obtain vaginal cultures to identify non-albicans species (present in 10-20% of recurrent cases), which respond less well to conventional azoles 1

Critical Considerations and Pitfalls

Avoid premature self-treatment:

• Over-the-counter preparations should only be used by women with previously confirmed VVC experiencing identical recurrent symptoms 1
• Inappropriate OTC use delays diagnosis of other vulvovaginal conditions and can worsen outcomes 1

Product interactions:

• Oil-based topical creams and suppositories weaken latex condoms and diaphragms 1, 2

Partner management:

• VVC is not sexually transmitted; routine partner treatment is not recommended 1
• Consider partner treatment only for recurrent infections 1
• Male partners with symptomatic balanitis benefit from topical antifungal treatment 1

Drug interactions with oral azoles:

• Fluconazole and other oral azoles interact with multiple medications including warfarin, calcium channel blockers, oral hypoglycemics, phenytoin, and protease inhibitors 1

Pregnancy considerations:

• Only 7-day topical azole therapies are recommended during pregnancy (avoid oral fluconazole) 1

Follow-Up

• Return for evaluation only if symptoms persist after completing treatment or recur within 2 months 1
• Women with ≥3 episodes per year require evaluation for predisposing conditions and consideration of maintenance therapy 2

Special Populations

HIV-infected patients:

• Treat with the same regimens as HIV-negative patients 1

Patients with ketoconazole maintenance therapy:

• Monitor for hepatotoxicity (occurs in 1 in 10,000-15,000 exposed patients) 1