What is the recommended treatment for vaginal yeast infections?

Treatment of Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, either a single dose of oral fluconazole 150 mg or short-course topical azole therapy (1-7 days) provides effective treatment with 80-90% cure rates. 1, 2

Diagnostic Confirmation Before Treatment

• Confirm diagnosis through clinical symptoms (pruritus, white discharge, vulvar erythema) plus laboratory evidence: wet mount with 10% KOH showing yeasts or pseudohyphae, or positive culture for yeast species 1, 2
• Vaginal pH must be normal (≤4.5) to support the diagnosis 1, 2
• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida without requiring treatment 1

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg as a single oral dose is highly effective for uncomplicated cases, achieving clinical cure in 80-90% of patients 1, 2, 3
• Oral therapy provides superior mycological cure compared to intravaginal treatment at both short-term and long-term follow-up 4

Intravaginal Therapy (Multiple Effective Options)

Short-course regimens (1-3 days):

• Clotrimazole 500 mg vaginal tablet, single application 1, 2
• Miconazole 200 mg vaginal suppository for 3 days 1, 2
• Terconazole 0.8% cream 5g intravaginally for 3 days 1, 2
• Tioconazole 6.5% ointment 5g intravaginally, single application 1, 2

Standard-course regimens (7 days):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1

Treatment Algorithm by Clinical Scenario

Uncomplicated VVC (Mild-to-Moderate, Sporadic, Non-Recurrent)

• Choose either single-dose oral fluconazole 150 mg OR any short-course (1-3 day) topical azole 1, 2
• Both routes achieve similar clinical cure rates (approximately 80-90%) 1, 4

Complicated VVC (Severe, Recurrent, or Immunocompromised Host)

• Requires extended therapy for 10-14 days with either topical or oral azoles 1, 2
• For recurrent VVC: two-phase approach with induction (10-14 days) followed by maintenance therapy with fluconazole 150 mg weekly for at least 6 months 2

Pregnancy

• Use only topical azole antifungals for 7 days—oral fluconazole is contraindicated 5, 2
• Recommended options: clotrimazole 1% cream for 7-14 days, miconazole 2% cream for 7 days, or terconazole 0.4% cream for 7 days 5
• Seven-day regimens are more effective than shorter courses during pregnancy 5

Over-the-Counter Self-Treatment

• OTC preparations (butoconazole, clotrimazole, miconazole, tioconazole) are available for self-treatment 1
• Advise self-treatment only for women previously diagnosed with VVC who have recurrence of identical symptoms 1, 2
• Women with persistent symptoms after OTC treatment or recurrence within 2 months must seek medical evaluation 1, 2

Important Considerations and Pitfalls

• Topical azole creams and suppositories are oil-based and may weaken latex condoms and diaphragms—refer to product labeling 1, 2
• Topical azoles are more effective than nystatin (80-90% vs. lower cure rates) 1, 5
• Complete the full treatment course even if symptoms improve early to prevent treatment failure 6
• If wet mount is negative but symptoms persist, obtain vaginal cultures before treating 2

Partner Management

• Do not treat sexual partners routinely, as VVC is not sexually transmitted 1, 2
• Exception: male partners with symptomatic balanitis (erythema on glans with pruritus) may benefit from topical antifungal treatment 1, 2

Follow-Up

• Patients should return only if symptoms persist after completing treatment or recur within 2 months 1, 2
• Persistent or recurrent symptoms require exclusion of reinfection, resistant organisms (such as Candida glabrata), or other conditions 2