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 any topical azole antifungal agent (no single topical agent is superior to another). 1

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg as a single oral dose is the most convenient option with 80-90% clinical and mycologic cure rates 1
• Achieves therapeutic concentrations in vaginal secretions rapidly and sustains them sufficiently for high response rates 2
• Relieves symptoms more rapidly than topical agents 3

Topical Intravaginal Therapy

Multiple equally effective options are available over-the-counter and by prescription 1:

Short-course regimens (1-3 days):

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

Longer-course regimens (7-14 days):

• Clotrimazole 1% cream 5 g for 7-14 days 1
• Miconazole 2% cream 5 g for 7 days 1
• Nystatin 100,000-unit vaginal tablet for 14 days 1

Important note: Topical azole drugs are more effective than nystatin 1

Treatment for Complicated Cases

Severe Acute Vulvovaginitis

Fluconazole 150 mg every 72 hours for 2-3 total doses (strong recommendation) 1

• Alternatively, use topical azole therapy for 7-14 days 1
• Severe disease is defined as extensive vulvar erythema, edema, excoriation, and fissure formation 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

Two-phase approach: 1

1. Induction phase: 10-14 days of topical azole OR oral fluconazole therapy
2. Maintenance phase: Fluconazole 150 mg once weekly for 6 months

This achieves control in >90% of patients, though 30-40% will have recurrence after stopping maintenance therapy 1

Non-albicans Candida Species (especially C. glabrata)

When azole therapy fails 1:

1. First-line: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days (70% eradication rate) 1
2. Second-line: Nystatin 100,000-unit intravaginal suppositories daily for 14 days 1
3. Third-line: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days 1

Critical caveat: C. glabrata is frequently unresponsive to oral azoles including voriconazole 1

Special Populations

Pregnancy

• Only topical azole therapy for 7 days should be used 1
• Oral fluconazole is NOT recommended during pregnancy 4, 5

HIV-Infected Women

• Use the same treatment regimens as HIV-negative women 1
• Identical response rates are expected regardless of HIV status 1

Immunocompromised or Diabetic Patients

• Require prolonged therapy (7-14 days) with conventional azole treatment 1
• Correct underlying modifiable conditions when possible 1

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization: 10-20% of women harbor Candida in the vagina without symptoms 1
• Confirm diagnosis before treatment: Use wet mount with 10% KOH to visualize yeast/pseudohyphae and confirm normal vaginal pH (<4.5) 1
• Self-treatment limitations: OTC preparations should only be used by women previously diagnosed with VVC who have recurrent identical symptoms 1
• Seek medical care if: Symptoms persist after OTC treatment or recur within 2 months 1
• Rule out STDs: If multiple sex partners, new partner, or symptoms include fever, foul-smelling discharge, or pelvic pain, evaluate for sexually transmitted infections 6