What is the recommended treatment for a vaginal yeast infection?

Treatment of Vaginal Yeast Infection

For uncomplicated vaginal yeast infections, use either a single 150 mg oral dose of fluconazole or a short-course topical azole (1-7 days depending on formulation), as both achieve 80-90% cure rates. 1

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg as a single oral dose is highly effective and convenient for uncomplicated cases 1
• Avoid fluconazole during pregnancy and use contraception during treatment plus 1 week after the final dose if pregnancy is possible 2

Topical Intravaginal Therapy

Short-course topical azoles are more effective than nystatin and equally effective as oral therapy 1:

Single-dose regimens:

• Clotrimazole 500 mg vaginal tablet, one application 1, 3
• Tioconazole 6.5% ointment 5 g, single application 1
• Butoconazole 2% sustained-release cream 5 g, single application 1

3-day regimens:

• Clotrimazole 100 mg vaginal tablet, two tablets daily for 3 days 1
• Miconazole 200 mg vaginal suppository, one daily for 3 days 1
• Terconazole 0.8% cream 5 g daily for 3 days 1
• Butoconazole 2% cream 5 g daily for 3 days 1

7-day regimens:

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

Diagnosis Confirmation

Before treating, confirm the diagnosis with: 1

• Clinical symptoms: vulvar pruritus, vaginal/vulvar erythema, white discharge (though symptoms alone are not specific) 1
• Vaginal pH ≤4.5 (normal pH; elevated pH suggests other causes) 1, 5
• Wet mount with 10% KOH showing yeasts or pseudohyphae, or positive culture 1

Critical pitfall: Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida without requiring treatment 1, 5

Complicated Cases Requiring Modified Approach

Use 7-day topical regimens (not single-dose) for: 1

• Severe symptoms or extensive vulvovaginal inflammation 1
• Pregnancy (topical azoles only; avoid oral fluconazole) 5, 2
• Diabetes or immunosuppression 1
• Non-albicans Candida species 1

For recurrent vulvovaginal candidiasis (≥4 episodes/year): 1, 6

• Initial treatment: 2 weeks of topical or oral azole therapy 1
• Maintenance therapy for 6 months: fluconazole 150 mg orally weekly, OR ketoconazole 100 mg daily, OR itraconazole 100 mg every other day, OR daily topical azole 1
• Obtain vaginal cultures to identify non-albicans species (present in 10-20% of recurrent cases), as these may require alternative therapy 1

Partner Management

Do not routinely treat sexual partners, as vaginal yeast infections are not sexually transmitted 1, 5

• Exception: Male partners with symptomatic balanitis (erythema and pruritus on glans) may benefit from topical antifungal treatment 1, 5

Over-the-Counter Self-Treatment

Miconazole and clotrimazole preparations are available OTC 1:

• Only recommend self-treatment for women previously diagnosed with VVC who recognize recurrent identical symptoms 1
• Women whose symptoms persist after OTC treatment or recur within 2 months must seek medical evaluation 1
• Major pitfall: Self-diagnosis is unreliable; incorrect diagnosis leads to overuse of antifungals, contact dermatitis, and delayed treatment of other vulvovaginal conditions 1

Important Safety Considerations

• Topical azole creams and suppositories are oil-based and may weaken latex condoms and diaphragms 1
• Oral azoles may cause nausea, abdominal pain, headache, and rarely liver enzyme elevations 1
• Fluconazole has significant drug interactions with: quinidine, erythromycin, pimozide, warfarin, calcium channel blockers, protease inhibitors, and others 1, 2

Follow-Up

Patients should return only if symptoms persist or recur within 2 months of initial treatment 1, 5