What medication is used to treat a vaginal yeast infection?

Treatment of Vaginal Yeast Infection

For uncomplicated vaginal yeast infections, use either a single 150 mg oral dose of fluconazole OR a short course of topical azole therapy (3-7 days), as both achieve equivalent cure rates of 80-90%. 1

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg as a single oral dose is the most convenient option for uncomplicated vulvovaginal candidiasis 1, 2
• Achieves clinical cure or improvement in 94% of patients at 14-day evaluation 3
• Therapeutic concentrations in vaginal secretions are rapidly achieved and sustained 4
• Well-tolerated with mostly mild, transient gastrointestinal side effects 4, 5

Topical Intravaginal Therapy

Multiple equally effective options are available over-the-counter and by prescription 1:

Short-course regimens (3 days):

• Butoconazole 2% cream 5g intravaginally 1
• Clotrimazole 100 mg vaginal tablet, two tablets 1
• Miconazole 200 mg vaginal suppository 1
• Terconazole 0.8% cream 5g intravaginally 1
• Terconazole 80 mg vaginal suppository 1

Single-dose regimens:

• Clotrimazole 500 mg vaginal tablet 1
• Tioconazole 6.5% ointment 5g 1

Longer regimens (7-14 days):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 6
• Miconazole 2% cream 5g intravaginally for 7 days 1

Complicated Vulvovaginal Candidiasis

For complicated infections (severe symptoms, recurrent disease, non-albicans species, immunocompromised host), use extended therapy: 1

• Fluconazole 150 mg every 72 hours for 3 doses (total of 3 doses over 6 days) 1, 7
• OR topical azole therapy for 7-14 days 1
• The 2-dose fluconazole regimen achieves significantly higher clinical cure rates in severe vaginitis (P=0.015) 7

Recurrent Vulvovaginal Candidiasis

For recurrent infections (≥4 episodes per year): 1

1. Induction phase: Topical agent or oral fluconazole for 10-14 days 1
2. Maintenance phase: Fluconazole 150 mg once weekly for at least 6 months 1
   • Achieves symptom control in >90% of patients 1
   • Alternative: Clotrimazole 200 mg twice weekly or 500 mg once weekly 1

Special Populations

Pregnancy

• Fluconazole can be used in pregnancy at 2g single dose for trichomoniasis per older guidelines 1
• However, for vaginal candidiasis in pregnancy, topical azole therapy is generally preferred 2
• Use birth control during fluconazole treatment and for 1 week after final dose if pregnancy is possible 2

HIV-Positive Women

• Treatment should not differ based on HIV status 1
• Identical response rates are anticipated for HIV-positive and HIV-negative women 1

Important Caveats

Confirm diagnosis before treatment: 1

• Wet mount with 10% KOH to demonstrate yeast or pseudohyphae 1
• Normal vaginal pH (≤4.5) 1
• 10-20% of asymptomatic women harbor Candida, so culture alone without symptoms should not prompt treatment 1

Self-treatment limitations: 1

• Over-the-counter preparations should only be used by women previously diagnosed with vaginal yeast infection who have recurrence of the same symptoms 1
• Seek medical care if symptoms persist after OTC treatment or recur within 2 months 1, 8

Non-albicans Candida species: 1, 7

• C. krusei responds to all topical antifungal agents but is fluconazole-resistant 1
• C. glabrata is problematic and frequently azole-resistant 1, 7
• For C. glabrata: Consider boric acid 600mg in gelatin capsules intravaginally, nystatin suppositories, or compounded 17% flucytosine cream ± 3% amphotericin B cream 1

Drug interactions with fluconazole: 2

• Do not use with quinidine, erythromycin, or pimozide 2
• Inform provider of all medications including those for organ transplant rejection or heart rhythm disturbances 2