Fluconazole (Diflucan) for Vulvovaginal Candidiasis
For uncomplicated vulvovaginal candidiasis, treat with a single oral dose of fluconazole 150 mg, which achieves over 90% clinical cure rates and is as effective as topical antifungals. 1, 2, 3
Treatment Algorithm Based on Disease Severity
Uncomplicated Vulvovaginal Candidiasis (90% of cases)
First-line options (equally effective):
- Single oral dose of fluconazole 150 mg 1, 3
- Topical antifungal agents (no specific agent superior to another) 1
The single-dose fluconazole regimen demonstrates excellent efficacy with 97% of patients cured or markedly improved at 5-16 days, and 88% cured at long-term follow-up (27-62 days) 4. In Japanese populations, the therapeutic efficacy rate was 74.7% on Day 28, with clinical cure rates of 81.6% 5. This represents a strong recommendation with high-quality evidence from the Infectious Diseases Society of America guidelines 1.
Severe Acute Vulvovaginal Candidiasis
For severe presentations, use fluconazole 150 mg every 72 hours for a total of 2-3 doses (strong recommendation; high-quality evidence) 1, 2. This extended regimen addresses the higher fungal burden and more intense inflammatory response seen in severe cases.
Recurrent Vulvovaginal Candidiasis (≥4 episodes per year)
Two-phase approach:
Phase 1 - Induction therapy (10-14 days):
Phase 2 - Maintenance therapy:
This maintenance regimen is highly effective: 90.8% of women remain disease-free at 6 months, 73.2% at 9 months, and 42.9% at 12 months, compared to only 21.9% in placebo groups at 12 months 6. The median time to clinical recurrence extends from 4.0 months (placebo) to 10.2 months with fluconazole 6. An alternative individualized decreasing-dose regimen (200 mg weekly for 2 months, then biweekly for 4 months, then monthly for 6 months) achieved 90% disease-free rates at 6 months and 77% at 1 year 7.
Special Considerations for Non-Albicans Species
C. glabrata Vulvovaginitis (Fluconazole-Resistant)
When oral azoles fail, use these alternatives in order of recommendation strength:
- Topical intravaginal boric acid 600 mg daily for 14 days (administered in gelatin capsule) - strong recommendation 1, 2
- Nystatin intravaginal suppositories 100,000 units daily for 14 days - strong recommendation 1, 2
- Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days - weak recommendation 1, 2
Importantly, long-term fluconazole maintenance therapy does not promote fluconazole resistance in C. albicans isolates or cause superinfection with C. glabrata 6.
Critical Clinical Pitfalls to Avoid
Diagnostic confirmation: Always confirm the diagnosis with microscopy and/or culture before initiating treatment, as symptoms of vulvovaginal candidiasis (pruritus, irritation, vaginal soreness, external dysuria, dyspareunia, thick white discharge) are nonspecific and can result from various other conditions 1, 2.
Disease classification: Distinguish between uncomplicated (90% of cases) and complicated vulvovaginal candidiasis (10% of cases), as this determines treatment duration 1, 2. Complicated disease includes severe or recurrent infections, non-albicans species, or infection in immunocompromised hosts 1.
Inadequate follow-up: Patients with recurrent or severe disease require close monitoring, as relapse rates can reach 23% even after initial successful treatment 4. Women experiencing multiple relapses during maintenance therapy often have longer disease duration and harbor more non-albicans Candida species 7.
Safety Profile
Fluconazole is well-tolerated with minimal side effects 3, 4, 5. The most common adverse events are mild gastrointestinal complaints including diarrhea and nausea (1.9% each) 5. Abnormal laboratory values occur in approximately 9% of patients but are minor and clinically insignificant 4. Headache rarely necessitates discontinuation 6.