What is the treatment for vaginal yeast infections?

Treatment for Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, use either a single 150 mg oral dose of fluconazole or a 7-day course of topical azole therapy; both are equally effective with 80-90% cure rates. 1, 2, 3

Uncomplicated Vulvovaginal Candidiasis (First Episode or Sporadic)

Oral Treatment Option

• Fluconazole 150 mg as a single oral dose is highly effective and convenient 2, 3
• This is the preferred option for most non-pregnant patients due to ease of administration 3

Topical Treatment Options (Equally Effective)

Choose any of the following intravaginal regimens 1:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Clotrimazole 100 mg vaginal tablet daily for 7 days 1
• Miconazole 2% cream 5g intravaginally for 7 days 1, 4
• Miconazole 200 mg vaginal suppository daily for 3 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 5

Topical azoles are more effective than nystatin and should be preferred. 1

Severe Vulvovaginal Candidiasis

For severe disease (extensive vulvar erythema, edema, excoriation, fissure formation), use either 7-14 days of topical azole therapy OR fluconazole 150 mg in two sequential doses (second dose 72 hours after the first). 1

• Short courses have lower clinical response rates in severe cases 1
• The extended duration is necessary to achieve adequate mycologic clearance 1

Recurrent Vulvovaginal Candidiasis (RVVC)

RVVC is defined as 3 or more symptomatic episodes within 12 months (updated from the previous definition of 4 or more episodes). 1, 6

Initial Treatment Phase

• Use 7-14 days of topical azole therapy OR fluconazole 150 mg repeated 3 days later to achieve mycologic remission before starting maintenance therapy 1
• Obtain vaginal cultures to confirm diagnosis and identify non-albicans species, particularly Candida glabrata 1

Maintenance Therapy (After Initial Clearance)

Continue maintenance therapy for 6 months with one of the following 1, 6:

• Fluconazole 100-150 mg once weekly (most commonly used) 1
• Clotrimazole 500 mg vaginal suppository once weekly 1
• Itraconazole 400 mg once monthly or 100 mg daily 1
• Ketoconazole 100 mg daily (requires hepatotoxicity monitoring due to 1 in 10,000-15,000 risk) 1

Important caveat: 30-40% of women will have recurrent disease once maintenance therapy is discontinued, and maintenance fluconazole improves quality of life in 96% of women but is uncommonly curative. 1

Non-Albicans Vulvovaginal Candidiasis

For non-albicans species (particularly C. glabrata), use 7-14 days of a non-fluconazole azole drug as first-line therapy. 1

If First-Line Treatment Fails

• Boric acid 600 mg in a gelatin capsule vaginally once daily for 2 weeks achieves approximately 70% clinical and mycologic eradication 1, 7
• This is the cheapest and easiest alternative option for resistant cases 7
• If non-albicans VVC continues to recur, consider nystatin 100,000 units vaginal suppository daily as maintenance 1

Critical consideration: C. glabrata shows significantly reduced susceptibility to azoles at vaginal pH 4 (normal) compared to laboratory pH 7, with terconazole showing >388-fold higher MIC at pH 4. 1

Special Populations

Pregnancy

Only topical azole therapies applied for 7 days are recommended during pregnancy; oral fluconazole should be avoided. 1, 5

• 7-day regimens are more effective than shorter courses in pregnancy 5
• Use contraception during fluconazole treatment and for 1 week after the final dose if pregnancy is possible 2
• Recommended options include clotrimazole 1% cream, miconazole 2% cream, or terconazole 0.4% cream for 7 days 5

HIV-Infected Women

Treatment for VVC in HIV-infected women should not differ from HIV-negative women. 1

• Vaginal Candida colonization rates are higher and correlate with immunosuppression severity 1
• Long-term prophylactic fluconazole 200 mg weekly is not recommended for routine primary prophylaxis 1

Immunocompromised or Diabetic Patients

Use prolonged therapy (7-14 days) with conventional azole treatment and correct modifiable conditions (e.g., optimize diabetes control). 1

Partner Management

Routine treatment of sex partners is not recommended, as VVC is not typically sexually transmitted. 1, 5

• Consider partner treatment only in women with recurrent infections 1
• Male partners with symptomatic balanitis (erythema on glans with pruritus) may benefit from topical antifungal treatment 1, 5

Emerging Therapies

Oteseconazole, a novel oral CYP51 inhibitor with long half-life, showed remarkably lower recurrence rates (4% vs 52% placebo) at 48 weeks in RVVC patients. 1

• This represents a promising new option for RVVC, though phase 3 trial analysis is pending 1
• A vaccine targeting Candida albicans hyphal virulence factor showed efficacy in reducing symptomatic VVC frequency for up to 12 months, but only in women under 40 years of age 1

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida in the vagina 1, 5
• Do not use nystatin as first-line therapy; topical azoles are significantly more effective 1, 5
• Do not assume all vaginal discharge is yeast; confirm diagnosis with wet mount showing yeasts/pseudohyphae or positive culture, especially for first episodes 1, 4
• Do not use short-course therapy for severe VVC, pregnancy, or recurrent cases; these require extended treatment duration 1, 5
• Do not forget to obtain cultures in recurrent cases to identify non-albicans species that may require alternative therapy 1