What is the treatment for Candida (fungal) vaginal infections?

Treatment of Candida Vaginal Infection

For uncomplicated vaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days), as both achieve >90% efficacy and are equally effective. 1, 2, 3

Classification Before Treatment

You must first classify the infection as uncomplicated versus complicated, as this determines therapy duration and approach 2:

Uncomplicated VVC (90% of cases):

• Sporadic or infrequent episodes (<4 per year) 2
• Mild to moderate symptoms 2
• Immunocompetent, non-pregnant women 2
• Caused by C. albicans 1

Complicated VVC (10% of cases):

• Severe symptoms 1
• Recurrent disease (≥4 episodes per year) 1, 2
• Non-albicans species (especially C. glabrata) 1, 2
• Immunocompromised host or pregnancy 1, 2

Diagnostic Confirmation Required

Do not treat empirically without confirmation, as self-diagnosis is unreliable 2, 4:

• Perform wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae 2, 4
• Verify normal vaginal pH (≤4.5) 1, 4
• Obtain vaginal cultures if microscopy is negative but suspicion remains 1, 4
• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida without infection 2, 4

Treatment Algorithm

For Uncomplicated VVC

Choose either oral or topical therapy based on patient preference 1, 2:

Oral option:

• Fluconazole 150 mg as single oral dose 1, 2, 3

Topical options (all equally effective):

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 2, 4
• Clotrimazole 100 mg vaginal tablet daily for 7 days 2, 4
• Miconazole 2% cream 5g intravaginally daily for 7 days 2, 4
• Miconazole 200 mg vaginal suppository daily for 3 days 2
• Tioconazole 6.5% ointment 5g intravaginally as single application 2, 4
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 2
• Terconazole 0.8% cream 5g intravaginally daily for 3 days 2
• Butoconazole 2% cream 5g intravaginally for 3 days 2, 4

For Complicated VVC

Severe symptoms:

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

Non-albicans species (C. glabrata):

• First-line: Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 1, 2, 4
• Azole therapy is frequently unsuccessful for C. glabrata 1
• For refractory cases: topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days (must be compounded) 1, 4

For Recurrent VVC (≥4 episodes/year)

Use a two-phase approach 1, 2:

Induction phase:

• 10-14 days of topical azole agent OR oral fluconazole 1, 2

Maintenance phase:

• Fluconazole 150 mg orally once weekly for 6 months 1, 2
• This achieves symptom control in >90% of patients 2
• Expect 40-50% recurrence rate after stopping maintenance therapy 1, 2

Special Population Considerations

Pregnancy:

• Avoid oral fluconazole entirely due to association with spontaneous abortion and congenital malformations 2
• Use only 7-day topical azole therapy 2

HIV-positive patients:

• Treatment regimens should be identical to HIV-negative women 2
• Equivalent response rates are expected 2

Critical Pitfalls to Avoid

Over-the-counter self-treatment:

• Only recommend for women previously diagnosed with VVC who experience identical recurrent symptoms 2, 4
• Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation 2, 4

Concurrent infections:

• VVC may be present concurrently with sexually transmitted diseases 2
• Maintain appropriate clinical suspicion and testing 2

Resistance considerations:

• Azole-resistant C. albicans infections are extremely rare 1, 4
• Non-albicans species are less responsive to azole therapy 2

Follow-up

• For uncomplicated infections with symptom resolution, follow-up is generally unnecessary 4
• For recurrent VVC, evaluate patients 1 month after completing induction therapy to verify efficacy before initiating maintenance therapy 2