What is the best treatment for a vaginal yeast infection?

Treatment of Vaginal Yeast Infection

For uncomplicated vaginal yeast infections, use either topical azole antifungals (clotrimazole 1% cream for 7-14 days or miconazole 2% cream for 7 days) or oral fluconazole 150 mg as a single dose, both achieving 80-90% cure rates. 1, 2

First-Line Treatment Options

Topical Azole Therapy (Preferred for Most Cases)

• Clotrimazole 1% cream 5g intravaginally for 7-14 days is highly effective and available over-the-counter 1, 3
• Clotrimazole 100 mg vaginal tablet for 7 days, or 500 mg as a single-dose tablet 1
• Miconazole 2% cream 5g intravaginally for 7 days provides equivalent efficacy 1
• Miconazole 200 mg vaginal suppository for 3 days or 100 mg suppository for 7 days 1
• Other effective options include butoconazole 2% cream for 3 days, tioconazole 6.5% ointment as single application, or terconazole formulations 1

Oral Therapy (Equally Effective Alternative)

• Fluconazole 150 mg orally as a single dose achieves 97% clinical cure at 5-16 days and 88% at long-term follow-up (27-62 days) 2, 4
• Oral therapy offers superior convenience compared to topical preparations 1
• The FDA-approved fluconazole specifically for vaginal yeast infections caused by Candida 2

Treatment Algorithm by Severity

Uncomplicated Mild-to-Moderate VVC

• Single-dose or short-course (1-3 day) regimens are appropriate 1
• Either oral fluconazole 150 mg once OR topical azole for 1-3 days 1, 2

Severe or Complicated VVC

• Multi-day regimens (7-14 days) are mandatory rather than single-dose treatments 1
• For severe infection, use fluconazole 150 mg orally every 72 hours for 2-3 doses (total treatment duration) 5
• Alternatively, extend topical azole therapy to 7-14 days 1

Recurrent VVC (≥3 Episodes in 12 Months)

• Initial induction therapy: 7-14 days of topical azole OR oral fluconazole 5
• Maintenance therapy: fluconazole 150 mg weekly for 6 months to prevent recurrence 5
• Evaluate for predisposing conditions (diabetes, immunosuppression, antibiotic use) 1

Special Populations

Pregnancy

• Use ONLY topical azole therapies applied for 7 days 5
• Oral fluconazole must be avoided during pregnancy 5, 2
• If pregnancy is possible, use contraception during fluconazole treatment and for 1 week after the final dose 2

Non-Albicans Candida Species (C. glabrata)

• Requires longer duration therapy (7-14 days) with non-fluconazole azole drugs 5
• Nystatin 100,000-unit vaginal tablet for 14 days may be more effective than fluconazole for C. glabrata (64.3% vs 12.5% cure rate) 5

Important Clinical Considerations

Diagnostic Confirmation

• Confirm diagnosis by visualizing yeast or pseudohyphae on 10% KOH wet mount or positive culture before treating 1
• Vaginal pH should be ≤4.5 in isolated Candida vaginitis 1
• Do not treat asymptomatic colonization—10-20% of women normally harbor Candida species without symptoms 1

Common Pitfalls to Avoid

• Self-medication with OTC preparations should only occur in women previously diagnosed with VVC who experience identical recurrent symptoms 1, 5
• Any woman whose symptoms persist after OTC treatment or recur within 2 months must seek medical evaluation 1, 5
• Oil-based vaginal creams and suppositories weaken latex condoms and diaphragms 1, 5
• Topical agents may cause local burning or irritation, though systemic side effects are rare 1

When Azoles Cannot Be Used

• Nystatin 100,000-unit vaginal tablet for 14 days is an alternative, though topically applied azoles are more effective than nystatin (80-90% vs lower cure rates) 1, 5

Follow-Up

• Patients should return only if symptoms persist after completing treatment or recur 1, 6
• Partner treatment is not routinely warranted as VVC is not sexually transmitted 1
• Male partners with symptomatic balanitis (erythema, pruritus on glans) may benefit from topical antifungal treatment 1