What is the recommended treatment for vaginal yeast infections?

Treatment for Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, use either oral fluconazole 150 mg as a single dose or topical azole therapy for 1-7 days, both achieving 80-90% cure rates. 1

First-Line Treatment Options

Oral Therapy (Preferred for Convenience)

• Fluconazole 150 mg oral tablet as a single dose is the most convenient first-line option for uncomplicated cases, with clinical cure rates of 80-90% 1
• Oral fluconazole is FDA-approved specifically for vaginal yeast infections caused by Candida 2
• Women should use contraception during treatment and for 1 week after the final dose if pregnancy is possible 2

Topical Therapy (Equally Effective)

Short-course regimens (1-3 days) for uncomplicated cases:

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

Standard 7-day regimens:

• Clotrimazole 1% cream 5g intravaginally for 7 days 3

• Miconazole 2% cream 5g intravaginally for 7 days 3

• Terconazole 0.4% cream 5g intravaginally for 7 days 3

• Note that topical azole creams and suppositories are oil-based and may weaken latex condoms and diaphragms 1

Confirming the Diagnosis Before Treatment

Do not treat without confirming the diagnosis, as only 10-20% of women normally harbor Candida without symptoms 3

• Diagnosis requires both clinical symptoms (vulvar pruritus, white discharge, vaginal/vulvar erythema) AND laboratory confirmation 3, 1
• Laboratory confirmation includes wet mount (saline or 10% KOH) showing yeasts or pseudohyphae, or positive culture 1
• Vaginal pH must be normal (≤4.5) for diagnosis of Candida vaginitis 3, 1
• If wet mount is negative but symptoms persist, obtain vaginal cultures 1

When to Use Longer Treatment Courses

Multi-day regimens (7-14 days) are required for complicated cases:

• Severe symptoms with extensive vulvar erythema, edema, excoriation, or fissure formation 1
• Recurrent infections (≥4 episodes per year) 3
• Non-albicans Candida species 1
• Immunocompromised patients (including HIV infection) 3, 1
• Pregnancy (see below) 3, 1

Special Population: Pregnancy

Only topical azole therapy should be used during pregnancy—oral fluconazole is contraindicated 3, 4

• 7-day topical azole regimens are more effective than shorter courses in pregnancy 4
• Recommended options include:
  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 4
  • Miconazole 2% cream 5g intravaginally for 7 days 4
  • Terconazole 0.4% cream 5g intravaginally for 7 days 4

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

Use a two-phase approach for recurrent infections:

• Induction phase: Topical azole or oral fluconazole for 10-14 days 1
• Maintenance phase: Fluconazole 150 mg once weekly for at least 6 months 1, 5

Resistant or Non-Albicans Cases

• For C. glabrata infections: Boric acid 600 mg gelatin capsules intravaginally daily for 14 days or topical nystatin 1
• Avoid nystatin as first-line therapy, as topical azoles are significantly more effective (80-90% cure rates vs. lower efficacy with nystatin) 4

Partner Management

Do not treat sexual partners routinely, as vulvovaginal candidiasis is not sexually transmitted 3, 1

• Exception: Male partners with symptomatic balanitis (erythematous glans with pruritus) may benefit from topical antifungal treatment 3, 1

Over-the-Counter Self-Treatment

• OTC miconazole and clotrimazole preparations are available for 7-day treatment courses 3
• Self-treatment should only be advised for women previously diagnosed with VVC who experience recurrence of identical symptoms 3, 1
• Women with persistent symptoms after OTC treatment or recurrence within 2 months must seek medical evaluation 3, 1

Follow-Up

• Patients should return only if symptoms persist or recur 3, 1
• Test of cure is not routinely needed for uncomplicated cases 3
• Women experiencing ≥3 episodes per year should be evaluated for predisposing conditions (diabetes, immunosuppression, antibiotic use) 3

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization—approximately 10-20% of women normally harbor Candida without requiring treatment 3, 4
• Do not use oral fluconazole in pregnancy—only topical azoles are safe 3, 4
• Do not reserve single-dose treatments for severe or complicated cases—these require multi-day regimens 3
• Be aware that fluconazole can cause QT prolongation, particularly in patients with structural heart disease, electrolyte abnormalities (especially hypokalemia), or those taking other QT-prolonging medications 2
• Avoid concomitant use of fluconazole with erythromycin due to increased risk of cardiotoxicity 2