What is the treatment for vaginal fungal infection?

Treatment of Vaginal Fungal Infection

For uncomplicated vaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole or topical azole therapy for 1-7 days, both achieving >90% efficacy. 1

Diagnostic Confirmation Required Before Treatment

• Confirm diagnosis with wet-mount preparation using 10% KOH to visualize yeast or pseudohyphae, and verify normal vaginal pH (≤4.5). 1, 2
• Do not treat asymptomatic colonization—10-20% of women normally harbor Candida species without infection. 1
• Obtain vaginal cultures for patients with negative wet-mount findings or suspected non-albicans species. 2

Classification Determines Treatment Duration

Uncomplicated Vaginal Candidiasis (90% of cases)

First-line treatment options (choose one):

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

• Topical therapy (1-7 day regimens):

  • Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 4, 1, 5
  • Miconazole 2% cream 5g intravaginally daily for 7 days 4, 1
  • Terconazole 0.4% cream 5g intravaginally daily for 7 days 4, 1
  • Butoconazole 2% cream 5g intravaginally as single application 1

• Topical and oral azole medications are equally effective, with both achieving 80-90% symptom relief and negative cultures. 4, 1

Complicated Vaginal Candidiasis (10% of cases)

Defined as: severe symptoms, recurrent disease (≥4 episodes/year), non-albicans species, or infection in immunocompromised hosts. 1, 2

Treatment approach:

• Fluconazole 150 mg every 72 hours for 2-3 doses 1, 2
• OR topical azole therapy for 7-14 days (longer courses required) 1, 6
• For non-albicans species (especially C. glabrata): boric acid 600 mg intravaginal capsule daily for 14 days 1, 2

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

Two-phase treatment protocol:

1. Induction phase: 10-14 days of topical azole agent or oral fluconazole 1, 2
2. Maintenance phase: Fluconazole 150 mg orally weekly for 6 months, achieving symptom control in >90% of patients 1, 6

• After cessation of maintenance therapy, expect 40-63% recurrence rate. 1, 2

Special Population Considerations

Pregnancy

• Avoid oral fluconazole completely—associated with spontaneous abortion and congenital malformations. 1, 2, 3
• Use only 7-day topical azole therapy in pregnant women. 1, 2
• Use birth control during treatment and for 1 week after final fluconazole dose if pregnancy is possible. 3

HIV-Positive Patients

• Treatment regimens should be identical to HIV-negative women, with equivalent response rates expected. 1, 2

Critical Pitfalls to Avoid

• Single-dose treatments should be reserved only for uncomplicated mild-to-moderate cases—patients with severe symptoms, recurrent disease, or complicated infection require extended therapy. 1
• Self-medication with over-the-counter preparations should only occur in women previously diagnosed with vaginal candidiasis who experience identical symptom recurrence. 4, 1
• Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses. 1
• Vaginal candidiasis may be present concurrently with sexually transmitted diseases—maintain appropriate clinical suspicion and testing. 4, 1
• Self-diagnosis of yeast vaginitis is unreliable; microscopic confirmation should be obtained before treatment. 1

Adverse Effects and Drug Interactions

• Topical agents rarely cause systemic side effects but may cause local burning or irritation. 4, 1
• Oral azoles may cause nausea, abdominal pain, and headache. 4, 1
• Fluconazole may interact with quinidine, erythromycin, pimozide, calcium channel antagonists, cisapride, coumadin, and protease inhibitors. 1, 3

Partner Management

• Vaginal candidiasis is not sexually transmitted; routine partner treatment is not warranted. 4
• Male partners with symptomatic balanitis (erythema on glans with pruritus) may benefit from topical antifungal treatment. 4