What is the treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

First-Line Treatment Approach

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% response rates and are equally effective. 1, 2

Classification Determines Treatment Duration

Before initiating therapy, classify the infection as uncomplicated versus complicated, as this fundamentally changes your treatment approach 1:

Uncomplicated VVC (90% of cases):

• Sporadic or infrequent episodes (<4 per year) 1
• Mild to moderate symptoms 1
• Immunocompetent, non-pregnant women 1
• Candida albicans as causative organism 1

Complicated VVC (10% of cases):

• Severe symptoms 1
• Recurrent disease (≥4 episodes/year) 1
• Non-albicans Candida species 1
• Abnormal host (pregnancy, uncontrolled diabetes, immunosuppression) 1

Treatment Regimens by Classification

Uncomplicated VVC

Choose one of the following equally effective options 1, 2:

Oral therapy:

• Fluconazole 150 mg as a single oral dose 1, 3

Topical therapy options 1:

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1
• Miconazole 2% cream 5g intravaginally daily for 7 days 1
• Miconazole 200 mg vaginal suppository daily for 3 days 1
• Tioconazole 6.5% ointment 5g intravaginally as single application 1
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 1
• Terconazole 0.8% cream 5g intravaginally daily for 3 days 1
• Butoconazole 2% cream 5g intravaginally as single application 1

Complicated VVC

For severe acute VVC:

• Fluconazole 150 mg every 72 hours for 2-3 doses 1, 2
• OR topical azole therapy for 7-14 days 1

For non-albicans species (especially C. glabrata):

• Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days (first-line for non-albicans) 1, 2
• OR nystatin intravaginal suppositories 2
• OR topical 17% flucytosine cream alone or combined with 3% amphotericin B cream 2

Recurrent VVC (≥4 episodes/year)

Use a two-phase approach 1, 2:

Induction phase:

• 10-14 days of topical azole agent OR oral fluconazole 1

Maintenance phase:

• Fluconazole 150 mg orally weekly for 6 months 1, 2
• This achieves symptom control in >90% of patients 1
• Expect 40-50% recurrence rate after cessation of maintenance therapy 1, 2

Special Population Considerations

Pregnancy

Avoid oral fluconazole completely in pregnancy due to association with spontaneous abortion and congenital malformations 1, 2:

• Use only topical azole therapy for 7 days 1, 2
• Longer duration (7 days) is required compared to non-pregnant women 1

HIV-Positive Women

• Treatment regimens should be identical to HIV-negative women 1, 2
• Expect equivalent response rates regardless of HIV status 1, 2

Critical Diagnostic Confirmation

Do not treat without microscopic confirmation, as self-diagnosis is unreliable 1:

• Perform wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae 1, 2
• Verify normal vaginal pH (≤4.5); higher pH suggests bacterial vaginosis or trichomoniasis 1, 2
• Obtain vaginal cultures for negative wet-mount findings or suspected non-albicans species 1
• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida without infection 1

Common Pitfalls to Avoid

Single-dose treatments are only for uncomplicated mild-to-moderate VVC 1:

• Patients with severe symptoms, recurrent disease, or complicated VVC require extended therapy 1

Self-medication with OTC preparations should only occur in women previously diagnosed with VVC who experience identical symptom recurrence 1:

• Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation 1

VVC may coexist with sexually transmitted diseases 1:

• Maintain appropriate clinical suspicion and testing for concurrent infections 1

Non-albicans species are less responsive to azole therapy 1:

• This is why culture identification matters in recurrent or treatment-resistant cases 1

Adverse Effects

Topical agents 1:

• Rarely cause systemic side effects 1
• May cause local burning or irritation 1

Oral fluconazole 1, 3:

• Most common: headache (13%), nausea (7%), abdominal pain (6%) 3
• Less common: diarrhea (3%), dyspepsia (1%), dizziness (1%), taste perversion (1%) 3
• Rare: hepatotoxicity, angioedema, anaphylactic reaction 3
• Drug interactions with astemizole, calcium channel antagonists, cisapride, warfarin, and protease inhibitors 1