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 or complicated, as this determines therapy duration and approach 3, 1:

Uncomplicated (90% of cases):

• Sporadic or infrequent episodes (<4 per year) 1
• Mild to moderate symptoms 1
• Immunocompetent, non-pregnant women 1
• Candida albicans as causative organism 3, 1

Complicated (10% of cases):

• Severe symptoms 3, 1
• Recurrent episodes (≥4 per year) 3, 1
• Non-albicans Candida species 3
• Immunocompromised host (including uncontrolled diabetes, HIV) 3, 1
• Pregnancy 1

Diagnostic Confirmation Required

Do not treat based on symptoms alone—self-diagnosis is unreliable and leads to overuse of antifungals with risk of contact dermatitis. 3, 1

Confirm diagnosis with 1:

• Wet-mount preparation with 10% KOH demonstrating yeast or pseudohyphae 3, 1
• Vaginal pH ≤4.5 (elevated pH suggests bacterial vaginosis or trichomoniasis) 1
• Vaginal culture if microscopy is negative but clinical suspicion remains high 1

Treatment Algorithm

Uncomplicated Vaginal Candidiasis

First-line options (choose one): 3, 1, 2

Oral therapy:

• Fluconazole 150 mg as single oral dose 2

Topical therapy (1-7 days depending on formulation):

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

Both routes achieve 80-90% symptom relief and negative cultures after therapy completion 1. Topical azoles are more effective than nystatin 1.

Complicated Vaginal Candidiasis

For severe symptoms or recurrent disease: 3, 1

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

For non-albicans species (C. glabrata, C. krusei): 3

• Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days (first-line for non-albicans) 3, 1, OR
• Topical flucytosine 3, OR
• Extended topical azole therapy for 7-14 days 3

Azole therapy is unreliable for non-albicans species 3.

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

Two-phase approach required: 3, 1

Phase 1: Induction therapy (after controlling causal factors like uncontrolled diabetes):

• Topical azole for 10-14 days 3, 1, OR
• Oral fluconazole for 10-14 days 1

Phase 2: Maintenance therapy for 6 months:

• Fluconazole 150 mg orally weekly (preferred) 3, 1, OR
• Ketoconazole 100 mg daily 3, OR
• Itraconazole 100 mg every other day 3, OR
• Daily topical azole 3

This achieves control of symptoms in >90% of patients 1. After cessation of maintenance therapy, expect 40-50% recurrence rate 1.

Special Population Considerations

Pregnancy

Avoid oral fluconazole in pregnancy due to association with spontaneous abortion and congenital malformations. 1

• Use only topical azole therapy for 7 days 1
• Single-dose topical regimens are insufficient in pregnancy 1

HIV-Positive Patients

Treatment regimens should be identical to HIV-negative women, with equivalent response rates expected 3, 1. No modification needed based on HIV status alone 3.

Patients on SGLT-2 Inhibitors

Most patients can continue their SGLT-2 inhibitor with appropriate antifungal treatment 4. Use standard topical azole therapy for 7 days 4.

Critical Pitfalls to Avoid

Do not treat asymptomatic colonization—10-20% of women normally harbor Candida species without infection 1. Treatment is only indicated for symptomatic infection.

Reserve single-dose treatments for uncomplicated mild-to-moderate cases only—patients with severe symptoms, recurrent disease, or complicated features require extended therapy 1.

Any woman whose symptoms persist after over-the-counter treatment or who experiences recurrence within 2 months must seek medical evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses 1.

Vaginal candidiasis may be present concurrently with sexually transmitted diseases—maintain appropriate clinical suspicion and testing 1.

For recurrent cases, obtain vaginal cultures to confirm diagnosis and identify non-albicans species before initiating long-term therapy 4.

Adverse Effects

Topical agents: Rarely cause systemic side effects but may cause local burning or irritation 3.

Oral azoles: May cause nausea, abdominal pain, headache 3, 2. Fluconazole may interact with astemizole, calcium channel antagonists, cisapride, warfarin, and protease inhibitors 1.

In clinical trials, gastrointestinal events were substantially more common with fluconazole (16%) compared to vaginal products (4%), though most events were mild to moderate 2.