Treatment of Vulvovaginal Candidiasis

For uncomplicated vulvovaginal candidiasis, give a single oral dose of fluconazole 150 mg, which achieves >90% clinical response rates. 1

Diagnostic Confirmation Before Treatment

Confirm diagnosis with wet mount preparation using 10% potassium hydroxide to visualize yeast or pseudohyphae, measure vaginal pH (should be ≤4.5), and obtain vaginal culture if wet mount is negative but symptoms persist 1
Symptoms of pruritus, vaginal discharge, dysuria, and dyspareunia are nonspecific and can result from multiple infectious and noninfectious causes, making diagnostic confirmation critical before initiating therapy 1
Do not treat asymptomatic colonization, as 10-20% of women harbor Candida species without symptoms and treatment is not indicated 1

Fluconazole 150 mg orally as a single dose is the first-line treatment 1
Alternative topical azole options include terconazole vaginal cream, which is FDA-approved for local treatment of vulvovaginal candidiasis 2
Both oral and topical treatments are equally effective for uncomplicated cases, though oral regimens are often preferred by patients 3

Fluconazole 150 mg every 72 hours for 3 doses (total 450 mg over 6 days) is recommended 1
Alternative: topical azole therapy for 5-7 days 1
Complicated cases include severe symptoms, non-albicans species, immunocompromised patients, or uncontrolled diabetes 1

Induction phase: Fluconazole 150 mg every 72 hours for 3 doses OR topical azole for 10-14 days 1
Maintenance phase: Fluconazole 150 mg weekly for 6 months 1
Alternative topical maintenance: clotrimazole, miconazole, terconazole, or intravaginal boric acid at one to three times weekly, with twice weekly dosing most commonly utilized 4
Identify and clear endogenous sources (oral cavity, intestine) and exogenous sources (sexual partner) of reinfection 5

First-line: Intravaginal boric acid 600 mg daily for 14 days in gelatin capsules 6
C. glabrata demonstrates resistance to azole antifungals, including fluconazole, making standard treatments ineffective 6
Alternative options: Nystatin intravaginal suppositories 100,000 units daily for 14 days OR topical 17% flucytosine cream with or without 3% amphotericin B cream daily for 14 days 6
Avoid fluconazole monotherapy for confirmed C. glabrata 6
Vaginal cultures are essential for proper identification, as C. glabrata doesn't form pseudohyphae or hyphae, making microscopy recognition difficult 6

Non-fluconazole azole drugs for 7-14 days as first-line therapy 6
Species identification influences treatment decisions, as conventional antimycotic therapies are less effective against non-albicans species compared to C. albicans 6

Recognize treatment failure patterns: If treatment fails, consider non-albicans species which may require alternative approaches (boric acid, nystatin, or topical flucytosine/amphotericin B combinations) 1
Oil-based creams and suppositories might weaken latex condoms and diaphragms, requiring counseling about potential contraceptive failure 6
Fluconazole and intravaginal boric acid should be avoided during pregnancy 4
Nystatin ovules may not be as effective as azoles for maintenance therapy 4

Clinical cure or improvement should be evident within 5-16 days 1
If symptoms persist after treatment or recur within 2 months, re-evaluate with repeat cultures to identify resistant or non-albicans species 1
Patients should return for follow-up if symptoms persist or recur after completing the treatment course 6