What is the treatment for vaginal fungal infection?

Treatment for Vaginal Fungal Infection

For uncomplicated vaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days), as both achieve >90% efficacy and are equally effective first-line options. 1

Confirm Diagnosis Before Treatment

• Perform wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae 1
• Verify normal vaginal pH (≤4.5) to confirm Candida infection 2, 1
• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida species without infection 1
• Obtain vaginal cultures if microscopy is negative but clinical suspicion remains high 1

Classification Determines Treatment Duration

Uncomplicated VVC (90% of cases): sporadic or infrequent episodes (<4 per year), mild-to-moderate symptoms, in immunocompetent non-pregnant women 1

Complicated VVC (10% of cases): severe symptoms, recurrent disease (≥4 episodes/year), non-albicans species, or infection in abnormal host (diabetes, immunosuppression) 1

First-Line Treatment Options

For Uncomplicated VVC

Oral therapy:

• Fluconazole 150 mg as single oral dose 2, 1, 3

Topical azole therapy (choose one):

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 2, 1, 4
• Clotrimazole 100 mg vaginal tablet daily for 7 days 2
• Miconazole 2% cream 5g intravaginally daily for 7 days 2, 1
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 2, 1, 5
• Butoconazole 2% cream 5g intravaginally for 3 days 2

For Complicated VVC

• Fluconazole 150 mg every 72 hours for 2-3 doses (total) 1
• OR topical azole therapy for 7-14 days (extended duration required) 1
• Single-dose treatments must be avoided in complicated cases 2, 1

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

Two-phase approach required:

Induction phase:

• 10-14 days of topical azole agent OR oral fluconazole 1

Maintenance phase:

• Fluconazole 150 mg orally weekly for 6 months 1
• This achieves symptom control in >90% of patients 1
• Expect 40-50% recurrence rate after cessation of maintenance therapy 1

Special Populations

Pregnancy

• Avoid oral fluconazole completely due to association with spontaneous abortion and congenital malformations 1
• Use only 7-day topical azole therapy (clotrimazole, miconazole, butoconazole, or terconazole) 2, 1

HIV-Positive Women

• Use identical treatment regimens as HIV-negative women 2, 1
• Expect equivalent response rates 1

Over-the-Counter Self-Treatment

• OTC preparations (miconazole, clotrimazole) should only be used by women previously diagnosed with VVC who experience identical recurrent symptoms 2, 1
• Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation 2, 1
• Self-diagnosis is unreliable; microscopic confirmation should be obtained before initial treatment 1

Important Clinical Pitfalls

• Do not use single-dose treatments for severe symptoms, recurrent disease, or complicated VVC - these require extended multi-day regimens 2, 1
• VVC may be present concurrently with sexually transmitted diseases; maintain appropriate clinical suspicion 2, 1
• Non-albicans Candida species are less responsive to azole therapy and may require boric acid 600 mg intravaginally daily for 14 days 1
• Partner treatment is not warranted, as VVC is not sexually transmitted 2

Adverse Effects

• Topical agents rarely cause systemic side effects but may cause local burning or irritation 2, 1
• Oral fluconazole may cause nausea, abdominal pain, and headache 2, 1
• Fluconazole interacts with multiple medications including warfarin, calcium channel blockers, and protease inhibitors 1, 3