What is the recommended treatment for vaginal yeast infections?

Treatment for Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, use either a single 150 mg oral dose of fluconazole or any topical azole antifungal agent for 1-7 days—both are equally effective with >90% cure rates. 1

Uncomplicated Vaginal Yeast Infections (90% of cases)

First-line treatment options (choose one):

Oral Therapy

• Fluconazole 150 mg as a single oral dose 1, 2
  • Achieves >90% response rate 1
  • Most convenient option for patients 1
  • FDA-approved for vaginal yeast infections 2

Topical Therapy (all equally effective)

No single topical agent is superior to another 1. Available options include:

• Clotrimazole (available over-the-counter) 1, 3:

  • 500 mg vaginal tablet as single dose, OR
  • 100 mg vaginal tablet daily for 7 days, OR
  • 1% cream 5g intravaginally for 7-14 days

• Miconazole (available over-the-counter) 1:

  • 200 mg vaginal suppository daily for 3 days, OR
  • 100 mg vaginal suppository daily for 7 days, OR
  • 2% cream 5g intravaginally for 7 days

• Other topical azoles: Terconazole, butoconazole, tioconazole 1

Important note: Oral and topical formulations achieve entirely equivalent results 1. The choice depends on patient preference and convenience.

Severe Acute Vaginal Yeast Infections

For severe presentations, use fluconazole 150 mg every 72 hours for a total of 2-3 doses 1

This extended regimen is necessary because:

• Severe infections require prolonged therapy 1
• Single-dose treatment is insufficient for complicated cases 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes per year)

Two-phase treatment approach 1:

Phase 1: Induction Therapy (10-14 days)

• Topical azole agent daily for 10-14 days, OR
• Oral fluconazole for 10-14 days 1

Phase 2: Maintenance Therapy (6 months)

• Fluconazole 150 mg once weekly for 6 months 1
• This achieves symptom control in >90% of patients 1
• After stopping maintenance, expect 40-50% recurrence rate 1

Special Situations

C. glabrata Infections (Azole-Resistant)

When infection is unresponsive to oral azoles, use one of the following 1:

1. Boric acid 600 mg intravaginal gelatin capsule daily for 14 days (first choice) 1
2. Nystatin 100,000 units intravaginal suppository daily for 14 days 1
3. Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

Critical point: Determine whether C. glabrata represents true infection versus colonization before treating 1

Pregnancy

• Use only topical azole therapy for 7 days 1
• Do NOT use oral fluconazole during pregnancy 1
• Clotrimazole, miconazole, butoconazole, and terconazole are effective options 1

HIV-Positive Patients

• Treat identically to HIV-negative patients 1
• Identical response rates are expected 1

Diagnostic Confirmation Before Treatment

Before starting empiric therapy, confirm diagnosis with 1:

• Wet-mount preparation with 10% KOH showing yeast or pseudohyphae
• Normal vaginal pH (≤4.5)
• If negative, obtain vaginal cultures for Candida 1

Common pitfall: Symptoms (pruritus, thick white discharge, dysuria) are nonspecific and can result from other infectious or noninfectious causes 1. Do not treat based on symptoms alone without microscopic confirmation.

Over-the-Counter Considerations

• Miconazole and clotrimazole are available OTC 1
• Self-treatment should only be advised for women previously diagnosed with VVC who have recurrent identical symptoms 1
• Any woman whose symptoms persist after OTC treatment or recur within 2 months should seek medical care 1

Warning: Unnecessary or inappropriate OTC use is common and delays treatment of other vulvovaginitis etiologies, potentially causing adverse outcomes 1

Partner Treatment

• Routine treatment of sex partners is NOT recommended 1
• VVC is not sexually transmitted 1
• Exception: Male partners with symptomatic balanitis may benefit from topical antifungal treatment 1