What is the recommended treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

For uncomplicated vaginal candidiasis (90% of cases), treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy for 1-7 days, both achieving >90% efficacy. 1, 2

Classification Before Treatment

Vaginal candidiasis must be classified as either uncomplicated (90%) or complicated (10%) before initiating therapy, as this determines treatment duration and approach. 1

Uncomplicated VVC is defined as:

• Sporadic or infrequent episodes (<4 per year) 1
• Mild to moderate symptoms 1
• Occurring in immunocompetent, non-pregnant women 1
• Caused by Candida albicans 1

Complicated VVC includes:

• Severe symptoms 1
• Recurrent disease (≥4 episodes per year) 1
• Non-albicans Candida species 1
• Immunocompromised hosts (diabetes, HIV, corticosteroid use) 1

Diagnostic Confirmation Required

Do not treat without confirming the diagnosis, as self-diagnosis is unreliable and only 33% accurate. 1

Confirm diagnosis through:

• Wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae 1, 2
• Verify normal vaginal pH (4.0-4.5)—higher pH suggests bacterial vaginosis or trichomoniasis 1, 2
• Vaginal cultures for patients with negative microscopy but persistent symptoms 1, 2

Critical caveat: Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida species without infection. 3, 1, 2

Treatment Algorithm

Uncomplicated VVC (First-Line Options)

Oral therapy (preferred by most patients for convenience):

• Fluconazole 150 mg orally as single dose 1, 2, 4

Topical therapy (equally effective, preferred in pregnancy):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 3, 1, 2
• Clotrimazole 100 mg vaginal tablet daily for 7 days 3, 2
• Miconazole 2% cream 5g intravaginally for 7 days 3, 2
• Butoconazole 2% cream 5g intravaginally for 3 days 3, 2
• Tioconazole 6.5% ointment 5g intravaginally as single application 2

All regimens demonstrate equivalent efficacy with 80-90% symptom relief and negative cultures. 3, 1

Complicated VVC (Requires Extended Therapy)

Severe symptoms or immunocompromised patients:

• Fluconazole 150 mg every 72 hours for 2-3 doses (total of 300-450 mg) 1, 4
• OR topical azole therapy for 7-14 days 1, 4

Non-albicans species (C. glabrata, C. krusei—inherently azole-resistant):

• First-line: Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 1, 2, 4
• Alternative: Nystatin 100,000 units intravaginally daily for 14 days 2
• Refractory cases: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days 2, 4

Non-albicans species are less responsive to azole therapy and require alternative agents. 1

Recurrent VVC (≥4 Episodes Per Year)

Two-phase approach is mandatory:

Induction Phase (achieve clinical and mycological remission):

• Topical azole for 10-14 days 1, 2
• OR oral fluconazole 150 mg every 72 hours for 3 doses 1

Maintenance Phase (suppress recurrence):

• Fluconazole 150 mg orally weekly for 6 months 1, 2, 4
• This achieves symptom control in >90% of patients during maintenance 1, 2

Critical limitation: After stopping maintenance therapy, expect 40-63% recurrence rate. 1, 2 Maintenance therapy improves quality of life in 96% of women but is rarely curative. 2

Alternative maintenance options include ketoconazole 100 mg daily or itraconazole 100 mg every other day, though fluconazole is preferred for superior pharmacokinetics and tolerability. 1, 2

Special Population Considerations

Pregnancy

Fluconazole is contraindicated in pregnancy, particularly the first trimester, due to associations with spontaneous abortion and congenital malformations. 1, 2

Use only topical azole therapy for 7 days in pregnant women. 1, 2 Oral azoles should be avoided throughout pregnancy. 1

HIV-Positive Women

Treatment regimens should be identical to HIV-negative women, with equivalent response rates expected. 1, 2 Lower CD4+ counts are associated with increased VVC rates, but treatment efficacy remains unchanged. 2

Over-the-Counter Self-Treatment

Reserve OTC preparations only for women previously diagnosed with VVC who experience recurrence of identical symptoms. 1, 2 Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses. 1, 2

Common Pitfalls and Adverse Effects

Oral fluconazole adverse effects (from single 150 mg dose):

• Headache (13%) 5
• Nausea (7%) 5
• Abdominal pain (6%) 5
• Rarely: angioedema and anaphylactic reactions 5

Topical azole adverse effects:

• Local burning or irritation (minimal systemic effects) 1
• Terconazole: headache (26%), vulvovaginal itching (most common reason for discontinuation) 6

Drug interactions with fluconazole: May interact with astemizole, calcium channel antagonists, cisapride, warfarin, and protease inhibitors. 1

Azole-resistant C. albicans is extremely rare but can occur after prolonged azole exposure. 4 VVC may be present concurrently with sexually transmitted diseases, so maintain appropriate clinical suspicion. 1

Follow-Up

For uncomplicated infections with symptom resolution, follow-up is unnecessary. 4 Reevaluation is recommended only if symptoms persist or recur within 2 months. 1