What is the treatment for vaginal yeast infections?

Treatment of Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, use either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days); for complicated cases (severe symptoms, recurrent infections, non-albicans species, or abnormal host factors), use extended therapy with either two 150 mg doses of fluconazole given 3 days apart or topical azoles for 7-14 days. 1, 2

Classification: Uncomplicated vs. Complicated

Uncomplicated VVC (90% of cases):

• Mild to moderate symptoms 1
• Sporadic or infrequent episodes 1
• Likely Candida albicans 1
• Normal, non-immunocompromised host 1

Complicated VVC (10% of cases):

• Severe symptoms (extensive vulvar erythema, edema, excoriation, fissure formation) 1
• Recurrent infections (≥4 episodes per year) 1
• Non-albicans Candida species 1
• Abnormal host (uncontrolled diabetes, immunosuppression, pregnancy) 1

First-Line Treatment for Uncomplicated VVC

Oral Option (Most Convenient):

• Fluconazole 150 mg as a single oral dose 1, 2, 3
• Clinical cure rates of 94-99% at 5-16 days post-treatment 4, 5, 6
• Mycologic eradication in 72-93% of patients 5, 6
• Symptoms typically resolve within 48-72 hours 1

Topical Options (Equally Effective):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 2
• Clotrimazole 500 mg vaginal tablet as single dose 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Butoconazole 2% cream 5g intravaginally for 3 days 1, 2
• Terconazole 0.4% cream 5g intravaginally for 7 days 1
• Tioconazole 6.5% ointment 5g as single application 1

Treatment for Complicated VVC

For Severe Symptoms:

• Fluconazole 150 mg on day 1 and day 4 (two doses, 3 days apart) achieves significantly higher cure rates than single-dose therapy 7
• Alternative: Any topical azole for 7-14 days 1

For Recurrent VVC (≥4 episodes/year):

• Initial treatment: 2 weeks of topical or oral azole therapy 1
• Maintenance therapy for 6 months with one of the following: 1
  • Fluconazole 150 mg orally every week 1
  • Ketoconazole 100 mg daily 1
  • Itraconazole 100 mg every other day 1
  • Daily topical azole 1

For Non-albicans Species (especially C. glabrata):

• Topical boric acid 600 mg intravaginally daily for 14 days 1
• Note: Azole therapy is unreliable for non-albicans species 1
• Non-albicans infection predicts significantly reduced response regardless of therapy duration 7

Diagnostic Confirmation Before Treatment

• Confirm diagnosis with wet mount (10% KOH preparation) showing yeasts or pseudohyphae, or positive culture 1, 2
• Vaginal pH should be ≤4.5 (normal) 1, 2
• Do NOT treat asymptomatic colonization—10-20% of women normally harbor Candida 1, 2

Critical Safety Considerations

Fluconazole Contraindications and Warnings:

• Avoid in pregnancy—use topical agents instead 3
• Use contraception during treatment and for 1 week after final dose 3
• Can cause QT prolongation; avoid in patients with hypokalemia, heart failure, or structural heart disease 3
• Do NOT combine with erythromycin, quinidone, or pimozide 3
• Caution with renal or hepatic dysfunction 3

Topical Agent Considerations:

• Oil-based creams and suppositories weaken latex condoms and diaphragms 1, 2
• Local burning or irritation may occur but is usually mild 1

Over-the-Counter Self-Treatment

• Clotrimazole, miconazole, butoconazole, and tioconazole are available OTC 1, 2, 8
• Self-treatment appropriate ONLY for women with previously confirmed diagnosis experiencing identical recurrent symptoms 1, 2
• Seek medical care if symptoms persist after OTC treatment or recur within 2 months 1, 2

Common Pitfalls to Avoid

Self-diagnosis is unreliable:

• Incorrect self-diagnosis leads to overuse of antifungals and risk of contact/irritant dermatitis 1
• Many conditions mimic VVC; confirmation is essential 1, 2

Partner treatment is unnecessary:

• VVC is not sexually transmitted 1, 2
• Routine partner notification or treatment does not reduce recurrence 1
• Exception: Male partners with symptomatic balanitis may benefit from topical antifungal treatment 1

Inadequate treatment duration for complicated cases:

• Single-dose or short-course therapy fails more often in severe or recurrent VVC 7
• Patients with history of recurrent vaginitis are significantly less likely to respond to standard therapy 4

Follow-Up

• Return only if symptoms persist or recur 1, 2
• Women with ≥3 episodes per year require evaluation for predisposing conditions (diabetes, immunosuppression, antibiotic use) 1, 2