What is the recommended treatment for a patient with a vaginal yeast infection?

Treatment of Vaginal Yeast Infection

For uncomplicated vaginal yeast infections, treat with either a single 150 mg oral dose of fluconazole or a short-course topical azole (1-7 days), as both achieve 80-90% clinical cure rates. 1

Confirm the Diagnosis First

Before treating, verify you have the correct diagnosis by checking:

• Clinical symptoms: pruritus, vulvovaginal erythema, and white discharge 1
• Laboratory confirmation: wet preparation or Gram stain showing yeasts or pseudohyphae, or positive culture 1
• Vaginal pH ≤4.5: elevated pH suggests bacterial vaginosis or trichomoniasis instead, not a yeast infection 1

First-Line Treatment Options

Oral therapy (most convenient):

• Fluconazole 150 mg as a single oral dose is the only FDA-approved oral agent and provides the most convenient option 1, 2
• Achieves therapeutic vaginal concentrations rapidly and sustains them sufficiently for cure 1
• Well tolerated with mild side effects (headache 13%, nausea 7%, abdominal pain 6%) 2

Topical therapy:

• Short-course topical azoles (1-3 days) or standard 7-day regimens achieve 80-90% cure rates 1
• Over-the-counter options include clotrimazole, miconazole, butoconazole, and tioconazole 1, 3
• More effective than nystatin 1

Modified Treatment for Complicated Cases

Severe vulvovaginitis (extensive erythema, edema, excoriation):

• Use either 7-14 days of topical azole therapy OR fluconazole 150 mg, two sequential doses 72 hours apart 1, 4
• The 2-dose fluconazole regimen achieves significantly higher clinical cure rates in severe cases (P=0.015) 4

Pregnancy:

• Use ONLY topical azole therapies applied for 7 days 1
• Avoid oral fluconazole due to potential teratogenicity 1, 2
• Use birth control while taking fluconazole and for 1 week after if pregnancy is possible 2

Compromised hosts (diabetes, immunosuppression, corticosteroid use):

• Prolonged conventional therapy for 7-14 days is necessary 1
• Short-term therapies have lower response rates in these populations 1

Critical Pitfalls to Avoid

Over-the-counter self-treatment:

• Only appropriate for women previously diagnosed with vaginal yeast infection who have recurrent identical symptoms 1
• Self-diagnosis is unreliable and leads to overuse of antifungals 1
• First-time symptoms require clinical evaluation and laboratory confirmation 1

Partner treatment:

• NOT routinely recommended, as vaginal yeast infection is not sexually transmitted 1, 5
• Treat male partners only if symptomatic balanitis (erythema, pruritus on glans) is present, using topical antifungals 1, 5

Follow-Up

• Return for follow-up only if symptoms persist or recur within 2 months 1
• Routine test-of-cure is unnecessary for uncomplicated cases 1
• If recurrent infections occur (≥4 episodes per year), obtain vaginal cultures to identify non-albicans species like Candida glabrata, which responds poorly to conventional azole therapy 5