From the Guidelines
Vaginal candidiasis is best treated with antifungal medications, and for uncomplicated cases, I recommend over-the-counter topical azoles like clotrimazole 1% cream applied intravaginally for 7 days, or fluconazole 150mg as a single oral dose, as supported by the 2021 Centers for Disease Control and Prevention guidelines 1.
Treatment Options
- Over-the-counter intravaginal agents:
- Clotrimazole 1% cream: 5 g intravaginally daily for 7–14 days
- Clotrimazole 2% cream: 5 g intravaginally daily for 3 days
- Miconazole 2% cream: 5 g intravaginally daily for 7 days
- Miconazole 4% cream: 5 g intravaginally daily for 3 days
- Prescription intravaginal agents:
- Butoconazole 2% cream (single dose bioadhesive product): 5 g intravaginally in a single application
- Terconazole 0.4% cream: 5 g intravaginally daily for 7 days
- Terconazole 0.8% cream: 5 g intravaginally daily for 3 days
- Oral agent:
- Fluconazole 150 mg: Single dose
Diagnosis and Considerations
- Diagnosis of vulvovaginal candidiasis can be made clinically, but confirmation with a wet-mount preparation or yeast culture is recommended, especially in cases with negative microscopy or when symptoms persist after treatment 1.
- Molecular testing, such as polymerase chain reaction (PCR), has shown high clinical accuracy for diagnosing vulvovaginal candidiasis, with sensitivity and specificity of 90.9% and 94.1%, respectively 1.
- Recurring vulvovaginal candidiasis requires induction therapy with a topical agent or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months, as recommended by the Infectious Diseases Society of America 1.
From the FDA Drug Label
Vaginal candidiasis: Two adequate and well-controlled studies were conducted in the U. S. using the 150 mg tablet. In both, the results of the fluconazole regimen were comparable to the control regimen (clotrimazole or miconazole intravaginally for 7 days) both clinically and statistically at the one month post-treatment evaluation The therapeutic cure rate, defined as a complete resolution of signs and symptoms of vaginal candidiasis (clinical cure), along with a negative KOH examination and negative culture for Candida (microbiologic eradication), was 55% in both the fluconazole group and the vaginal products group Fluconazole PO 150 mg tablet Vaginal Product qhs x 7 days Enrolled 448 422 Evaluable at Late Follow-up 347 (77%) 327 (77%) Clinical cure 239/347 (69%) 235/327 (72%) Mycologic eradication 213/347 (61%) 196/327 (60%) Therapeutic cure 190/347 (55%) 179/327 (55%)
Vaginal Candidiasis Treatment with Fluconazole:
- The therapeutic cure rate for vaginal candidiasis with fluconazole was 55%
- Clinical cure was achieved in 69% of patients
- Mycologic eradication was achieved in 61% of patients 2
From the Research
Treatment Options for Vaginal Candidiasis
- A single oral dose of 150 mg fluconazole has been shown to be effective in treating vaginal candidiasis, with a clinical response rate of 97% and a cure rate of 88% at long-term assessment 3.
- Fluconazole has been compared to intravaginal clotrimazole in the treatment of vaginal candidiasis, with fluconazole showing a significant advantage in terms of long-term efficacy and rapid relief of symptoms 4.
- A combined treatment approach using systemic fluconazole and topical metronidazole and clotrimazole has been proposed for the treatment and prophylaxis of recurrent candidiasis, aiming to address the underlying causes of recurrence 5.
- Single-dose systemic oral fluconazole has been found to be safe and effective in the treatment of vaginal candidiasis, with high patient satisfaction and compliance rates 6.
- Oral fluconazole has been shown to be as effective as intravaginal antifungal agents in the treatment of vaginal candidiasis, with the added benefits of ease of administration and low rate of side effects 7.
Efficacy and Safety of Fluconazole
- Fluconazole has been found to be effective in eradicating Candida from the vagina, with a rate of 93% at short-term assessment and 73% at long-term assessment 3.
- The incidence of side-effects with fluconazole is low, with mainly mild gastrointestinal complaints reported 3.
- Fluconazole has been found to be safe and well-tolerated, with abnormal laboratory test results occurring in only 15 of 167 evaluable patients, all of which were minor and of minimal clinical significance 3.
Comparison with Other Treatments
- Fluconazole has been compared to intravaginal clotrimazole, with fluconazole showing a significant advantage in terms of long-term efficacy and rapid relief of symptoms 4.
- A combined treatment approach using systemic fluconazole and topical metronidazole and clotrimazole has been proposed as a potential alternative to traditional treatments for recurrent candidiasis 5.