What is the recommended treatment for a vaginal yeast infection?

Treatment of Vaginal Yeast Infection

For uncomplicated vaginal yeast infections, use either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-3 days), both achieving 80-90% cure rates. 1, 2

Confirming the Diagnosis First

Before initiating treatment, confirm the diagnosis with:

• Clinical symptoms: pruritus, white vaginal discharge, vulvar erythema, burning, dyspareunia, or external dysuria 1
• Laboratory confirmation: wet mount (10% KOH or saline) showing yeasts or pseudohyphae, OR positive culture 1, 2
• Normal vaginal pH (<4.5) is characteristic of VVC 1, 2

Important caveat: Do not treat asymptomatic Candida colonization, as 10-20% of women harbor Candida without requiring treatment 1, 3

First-Line Treatment Options for Uncomplicated VVC

Oral Therapy (Preferred for Convenience)

Fluconazole 150 mg as a single oral dose 1, 2, 4

• Achieves 97% clinical cure at 5-16 days and 88% at long-term follow-up 5
• FDA-approved specifically for vaginal yeast infections 4
• Well-tolerated with minimal gastrointestinal side effects 5

Topical Azole Therapy (Equally Effective)

Short-course regimens (1-3 days) include: 1, 2

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

Critical warning: Oil-based creams and suppositories may weaken latex condoms and diaphragms 1, 2

Special Populations Requiring Modified Treatment

Pregnant Women

Use only topical azole antifungals for 7 days—oral fluconazole is contraindicated 1, 3, 2

• Recommended options: clotrimazole 1% cream for 7-14 days, miconazole 2% cream for 7 days, or terconazole 0.4% cream for 7 days 3
• Seven-day regimens are more effective than shorter courses during pregnancy 3
• Women of childbearing potential should use contraception while taking fluconazole and for 1 week after the final dose 4

Severe VVC

For extensive vulvar erythema, edema, excoriation, or fissure formation: 1

• Either 7-14 days of topical azole therapy OR fluconazole 150 mg in two sequential doses (72 hours apart) 1

Recurrent VVC (≥3 episodes per year)

Two-phase approach: 1, 2

1. Induction phase: 7-14 days of topical azole OR oral fluconazole (150 mg repeated 3 days later) 1, 2
2. Maintenance phase: Fluconazole 150 mg once weekly for at least 6 months 1, 2

Important limitation: 30-40% of women experience recurrence after discontinuing maintenance therapy, and 63% may have ongoing infections despite completing treatment 1

Non-albicans Candida Species

For C. glabrata or other non-albicans species: 1, 2

• First-line: 7-14 days of non-fluconazole azole therapy 1
• If recurrent: Boric acid 600 mg gelatin capsules intravaginally daily for 14 days (70% cure rate) 1, 2
• Alternative: Nystatin 100,000-unit vaginal suppository daily for maintenance 1

Critical consideration: Non-albicans species show significantly reduced azole susceptibility at vaginal pH 4, particularly C. glabrata with terconazole (388-fold higher MIC), which may contribute to treatment failure 1

Partner Management

Do not treat sexual partners routinely—VVC is not sexually transmitted 1, 2

• Exception: Male partners with symptomatic balanitis may benefit from topical antifungal treatment 3, 2

Over-the-Counter Self-Treatment

Advise OTC preparations only for women previously diagnosed with VVC who have identical recurrent symptoms 1, 2

• Women with persistent symptoms after OTC use or recurrence within 2 months must seek medical evaluation 1, 2
• OTC preparations (butoconazole, clotrimazole, miconazole, tioconazole) are available but require 7-day courses 1

Follow-Up Recommendations

Patients should return only if symptoms persist or recur within 2 months 1, 2

• Persistent symptoms warrant evaluation for resistant infection, non-albicans species, or alternative diagnoses 3

Common Pitfalls to Avoid

• Do not use nystatin as first-line therapy—topical azoles are significantly more effective (80-90% vs. lower cure rates) 1, 3
• Do not prescribe oral fluconazole during pregnancy—teratogenic risk requires topical therapy only 1, 3
• Do not ignore pH testing—pH >4.5 suggests alternative diagnoses like bacterial vaginosis or trichomoniasis 1
• Do not assume all recurrences are C. albicans—10-20% of recurrent cases involve non-albicans species requiring different treatment 1