Treatment of Vaginal Yeast Infections with Fluconazole
For uncomplicated vaginal yeast infections, a single oral dose of fluconazole 150 mg is the recommended treatment, achieving clinical cure rates of 90-97% and offering equivalent efficacy to topical antifungal agents with superior convenience. 1
Uncomplicated Vaginal Candidiasis
First-line treatment:
- Single dose: Fluconazole 150 mg orally once 1, 2
- This achieves therapeutic vaginal concentrations within hours and maintains them for sufficient duration to eradicate infection 3
- Clinical cure or improvement occurs in 94-97% of patients by day 14 4
- Mycologic eradication rates reach 77% at 14 days and 73% at long-term follow-up 5
Alternative option:
- Topical intravaginal antifungal agents (no single agent superior to another) for patients who prefer local therapy 1
Severe Acute Vaginal Candidiasis
For severe symptoms (marked vulvar edema, erythema, excoriation, or extensive lesions):
- Fluconazole 150 mg every 72 hours for 2-3 total doses 1
- The multi-dose regimen achieves significantly higher clinical cure rates in severe disease compared to single-dose therapy (P=0.015 at day 14) 6
- Superior mycologic eradication persists at day 35 with the extended regimen 6
Recurrent Vulvovaginal Candidiasis
Defined as ≥4 episodes per year:
Induction phase:
- 10-14 days of therapy with either topical agent OR oral fluconazole 1
- Fluconazole 150 mg every 72 hours for 2-3 doses is appropriate 1
Maintenance phase:
- Fluconazole 150 mg weekly for 6 months 1, 7
- This regimen keeps 90.8% of women disease-free at 6 months versus 35.9% with placebo (P<0.001) 7
- Median time to recurrence extends to 10.2 months versus 4.0 months without maintenance therapy 7
- After stopping maintenance therapy, 42.9% remain disease-free at 12 months 7
Non-albicans Species
For C. glabrata vulvovaginitis unresponsive to oral azoles:
- Topical intravaginal boric acid 600 mg daily in gelatin capsule for 14 days 1
- Alternative: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
- Non-albicans Candida predicts significantly reduced clinical and mycologic response regardless of therapy duration 6
Important Clinical Considerations
Contraindications to fluconazole:
- Concurrent use of quinidine, erythromycin, or pimozide 2
- Known hypersensitivity to fluconazole or azole antifungals 2
Special populations requiring caution:
- Pregnancy: Avoid fluconazole; use topical agents instead 2
- Women of childbearing potential should use contraception during treatment and for 1 week after final dose 2
- Breastfeeding: Fluconazole passes into breast milk; discuss risks/benefits 2
Common pitfall: Patients with history of recurrent vaginitis (≥4 episodes/year) are significantly less likely to respond to single-dose therapy compared to those without recurrence history (P<0.001) 4. These patients require the extended induction and maintenance regimen described above.
Adverse effects:
- Generally mild and transient, occurring in 15-27% of patients 4, 5
- Most common: gastrointestinal symptoms (nausea, abdominal discomfort) 5, 3
- Serious adverse effects are rare with single or short-course therapy 6
No evidence of fluconazole resistance development with long-term weekly maintenance therapy, and no increased risk of C. glabrata superinfection 7