What is the recommended treatment for a patient with vaginal candidiasis, considering their medical history and potential underlying conditions such as diabetes or impaired immune function?

Treatment of Vaginal Candidiasis

For uncomplicated vaginal candidiasis, treat with a single oral dose of fluconazole 150 mg, which achieves >90% clinical response and is as effective as topical therapy. 1

Diagnostic Confirmation Before Treatment

Before initiating therapy, confirm the diagnosis rather than treating empirically:

• Perform wet mount preparation with 10% potassium hydroxide to visualize yeast or pseudohyphae 2
• Measure vaginal pH, which should be ≤4.5 for candidiasis (higher pH suggests bacterial vaginosis or trichomoniasis) 2
• Obtain vaginal culture if wet mount is negative but symptoms persist 1, 2

The clinical presentation of pruritus, vaginal discharge, dysuria, and dyspareunia is nonspecific and can result from multiple infectious and noninfectious causes, making laboratory confirmation critical before treatment. 1

Treatment Algorithm Based on Disease Severity

Uncomplicated Vulvovaginal Candidiasis (90% of cases)

First-line therapy: Fluconazole 150 mg orally as a single dose 1, 2

• Achieves clinical cure or improvement in 94-97% of patients at 14 days 3, 4
• Mycologic eradication occurs in 72-77% at short-term follow-up 3, 5
• Symptoms typically resolve within 5-16 days 4, 6

Alternative: Topical azole therapy (if oral therapy contraindicated) 1

• No evidence shows superiority of any specific topical regimen 1
• Oral and topical formulations achieve entirely equivalent results 1

Severe Acute Vulvovaginal Candidiasis

Fluconazole 150 mg every 72 hours for 2-3 doses (total 300-450 mg over 6 days) 1, 2

• The 2-dose regimen achieves significantly higher clinical cure rates in severe disease (P=0.015 at day 14) 7
• Higher clinical and mycologic responses persist at day 35 compared to single-dose therapy 7

Alternative: Topical azole therapy for 5-7 days 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes per year)

Two-phase approach: 1, 2

1. Induction phase: Fluconazole 150 mg every 72 hours for 3 doses OR topical azole for 10-14 days 1, 2
2. Maintenance phase: Fluconazole 150 mg weekly for 6 months 1, 2

• This regimen achieves symptom control in >90% of patients 1
• After cessation of maintenance therapy, expect 40-50% recurrence rate 1
• Most cases are caused by azole-susceptible C. albicans, and contributing factors like diabetes are rarely found 1

Special Considerations for Non-Albicans Species

Candida glabrata Infection

This is the most problematic non-albicans species, as azole therapy (including voriconazole) is frequently unsuccessful. 1

First, determine if this represents true infection versus colonization (10-20% of women harbor Candida asymptomatically). 2

If treatment is indicated: 1

1. First-line: Intravaginal boric acid 600 mg daily for 14 days (compounded in gelatin capsules) 1
2. Second-line: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
3. Third-line: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 1

Multivariate analysis shows that non-albicans Candida infection predicts significantly reduced clinical and mycologic response regardless of therapy duration. 7

Candida krusei Infection

Responds to all topical antifungal agents but is intrinsically resistant to fluconazole 1

Considerations for Immunocompromised Patients

HIV-Infected Patients

Treatment should not differ based on HIV status - identical response rates are anticipated for HIV-positive and HIV-negative women. 1

Use the same treatment algorithms as immunocompetent patients based on disease severity. 1

Diabetes

Diabetes is rarely a contributing factor in recurrent vulvovaginal candidiasis, but when present, optimize glycemic control alongside antifungal therapy. 1

Pediatric Dosing Considerations

For adolescents (age 15 and older):

Use the standard adult dose of fluconazole 150 mg as older children have clearances similar to adults. 2, 8

For younger children requiring treatment:

• Weight-based dosing of 6 mg/kg may be used 8
• However, the fixed adult dose of 150 mg is more appropriate for most children over 6 years to avoid potential overexposure 2

Critical Pitfalls to Avoid

Do not treat asymptomatic colonization - 10-20% of women harbor Candida species without symptoms, and treatment is not indicated. 2

Recognize treatment failure patterns:

• If symptoms persist after treatment or recur within 2 months, re-evaluate with repeat cultures 2
• Consider non-albicans species (particularly C. glabrata) if standard fluconazole therapy fails 1, 2
• Azole-resistant C. albicans is extremely rare but can occur following prolonged azole exposure 1

Avoid empiric treatment without diagnostic confirmation - the symptoms are nonspecific and multiple other conditions present similarly. 1, 2

Safety Profile

Fluconazole is generally well tolerated:

• Most common side effects: headache (13%), nausea (7%), abdominal pain (6%), diarrhea (3%) 8, 3
• Most side effects are mild to moderate in severity 8, 3
• Treatment discontinuation due to adverse events occurs in only 1.5% of patients 8
• Serious hepatic reactions are rare and occur primarily in patients with serious underlying conditions taking multiple concomitant medications 8

Follow-Up Expectations

Clinical cure or improvement should be evident within 5-16 days 2, 4

If symptoms persist beyond this timeframe or recur within 2 months, the patient requires re-evaluation with repeat cultures to assess for:

• Non-albicans species 2
• Azole resistance 1
• Alternative diagnoses 1