What is the recommended treatment for fungal vaginitis?

Treatment of Fungal Vaginitis

For uncomplicated fungal vaginitis, prescribe either fluconazole 150 mg as a single oral dose or a short-course topical azole (1-3 days), both achieving 80-90% cure rates. 1

Confirming the Diagnosis First

Before initiating treatment, confirm the diagnosis through laboratory testing rather than treating empirically:

• Perform wet mount microscopy (using saline or 10% KOH) to visualize yeasts or pseudohyphae, or obtain a positive culture for yeast species 1
• Verify vaginal pH is normal (<4.5), as elevated pH suggests alternative diagnoses like bacterial vaginosis or trichomoniasis 2
• If wet mount is negative but symptoms persist, obtain vaginal cultures before treating 1

Clinical symptoms alone (pruritus, erythema, white discharge, dyspareunia) are not specific enough to reliably diagnose vulvovaginal candidiasis without microscopic or culture confirmation 2

First-Line Treatment for Uncomplicated Cases

Oral Option (Most Convenient)

• Fluconazole 150 mg as a single oral dose is the preferred oral agent, providing equivalent efficacy to topical regimens 2, 1
• Common side effects include headache (13%), nausea (7%), and abdominal pain (6%), which are typically mild 3
• Avoid in patients taking medications with significant drug interactions (calcium channel blockers, warfarin, oral hypoglycemics, phenytoin, protease inhibitors) 2

Topical Options (Equally Effective)

Short-course regimens (1-3 days) are as effective as longer courses for uncomplicated cases 2:

• Clotrimazole 500 mg vaginal tablet, single application 2
• Miconazole 200 mg vaginal suppository for 3 days 2
• Terconazole 0.8% cream 5g intravaginally for 3 days 2
• Tioconazole 6.5% ointment 5g intravaginally, single application 2

Critical caveat: Oil-based creams and suppositories weaken latex condoms and diaphragms 2, 1

When to Use Extended Treatment (7-14 Days)

Prescribe longer-duration therapy for complicated vulvovaginal candidiasis, defined as:

• Severe symptoms (extensive vulvar erythema, edema, excoriation, fissure formation) 1
• Recurrent infections (4 or more episodes per year) 2, 1
• Non-albicans Candida species (particularly C. glabrata, which responds poorly to standard azoles) 2
• Immunocompromised patients (diabetes, HIV, corticosteroid use) 1
• Pregnancy (topical azoles only for 7 days; oral fluconazole is contraindicated) 1

For severe cases, use either 7-14 days of topical azole therapy or fluconazole 150 mg repeated 3 days after the initial dose 2, 4. Research demonstrates that women with severe vaginitis achieve significantly higher clinical cure rates with the 2-dose fluconazole regimen compared to single-dose treatment (P=0.015) 4

Management of Recurrent Vulvovaginal Candidiasis

For women with 4 or more episodes annually:

Induction Phase

• Prescribe topical azole for 7-14 days OR oral fluconazole 150 mg on days 1,4, and 7 to achieve initial mycologic remission 2, 1
• Obtain vaginal cultures to identify non-albicans species (present in 10-20% of recurrent cases), which require alternative therapy 2

Maintenance Phase

• Fluconazole 150 mg once weekly for at least 6 months to maintain clinical and mycologic control 1, 5
• This maintenance regimen significantly reduces recurrence rates 5

Alternative for Non-Albicans Species

• Boric acid 600 mg gelatin capsules intravaginally daily for 14 days for C. glabrata infections resistant to azoles 1
• Topical nystatin is another option, though requires 14 days of treatment 2

Over-the-Counter Self-Treatment

Advise OTC preparations only for women previously diagnosed with vulvovaginal candidiasis who recognize identical recurrent symptoms 2, 1:

• Available OTC agents include butoconazole, clotrimazole, miconazole, and tioconazole 2
• OTC formulations require 7-day treatment courses (longer than prescription short-course options) 1
• Women with persistent symptoms after OTC treatment or recurrence within 2 months must seek medical evaluation to avoid delays in diagnosing alternative conditions 2, 1

Partner Management

Do not treat sexual partners routinely, as vulvovaginal candidiasis is not sexually transmitted 1:

• Exception: Male partners with symptomatic balanitis (erythema, pruritus on glans penis) may benefit from topical antifungal treatment 2, 1
• Partner treatment may be considered in women with recurrent infections, though evidence is limited 2

Follow-Up

Instruct patients to return only if symptoms persist after treatment or recur within 2 months 2, 1. Routine test-of-cure is unnecessary for uncomplicated cases that respond clinically 1