What is the recommended treatment for vaginal candidiasis?

Treatment of Vaginal Candidiasis

First-Line Treatment Recommendation

For uncomplicated vaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days), as both achieve >90% efficacy and are equally effective. 1, 2

Classification Before Treatment

Vaginal candidiasis must be classified as either uncomplicated (90% of cases) or complicated (10% of cases) before initiating therapy, as this determines treatment duration and approach 1:

Uncomplicated VVC includes:

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

Complicated VVC includes:

• Severe symptoms 1
• Recurrent episodes (≥4 per year) 1
• Non-albicans Candida species 1
• Immunocompromised hosts (including HIV, diabetes, pregnancy) 1

Diagnostic Confirmation Required

Do not treat without confirming diagnosis, as 10-20% of women normally harbor Candida species without infection 3, 1:

• Perform wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae 3, 1
• Verify normal vaginal pH (≤4.5) 3, 1
• Obtain vaginal cultures if microscopy is negative but clinical suspicion remains high 1

Treatment Regimens for Uncomplicated VVC

Oral Therapy Option

Fluconazole 150 mg as a single oral dose 3, 2

• Achieves 55% therapeutic cure rate (complete symptom resolution plus negative culture) at one month 2
• Clinical cure rate of 69-80% 2, 4
• More gastrointestinal side effects (16% drug-related events) compared to topical therapy (4%) 2

Topical Azole Options (All Equally Effective)

Short-course regimens (1-3 days): 3, 1

• Clotrimazole 500 mg vaginal tablet, single application 3
• Miconazole 200 mg vaginal suppository daily for 3 days 3
• Tioconazole 6.5% ointment 5 g intravaginally, single application 3
• Terconazole 0.8% cream 5 g intravaginally daily for 3 days 3
• Butoconazole 2% sustained-release cream 5 g, single application 3

Longer-course regimens (7-14 days): 3, 1

• Clotrimazole 1% cream 5 g intravaginally daily for 7-14 days 3
• Miconazole 2% cream 5 g intravaginally daily for 7 days 3
• Terconazole 0.4% cream 5 g intravaginally daily for 7 days 3

Important caveat: Oil-based creams and suppositories may weaken latex condoms and diaphragms 3

Treatment for Complicated VVC

For severe symptoms, recurrent disease, non-albicans species, or immunocompromised hosts, use extended therapy: 1

• Fluconazole 150 mg every 72 hours for 2-3 doses (total of 300-450 mg) 1
• OR topical azole agents for 7-14 days 1

For non-albicans species specifically: Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days is first-line 1

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

Use a two-phase treatment approach: 1, 5

Induction Phase:

• 10-14 days of topical azole agent 1
• OR oral fluconazole (any regimen to achieve clinical and mycological remission) 1

Maintenance Phase:

• Fluconazole 150 mg orally weekly for 6 months 1, 5
• Achieves symptom control in >90% of patients during maintenance 1
• Critical caveat: 40-50% recurrence rate after cessation of maintenance therapy 1

Special Population Considerations

Pregnancy

Avoid oral fluconazole completely due to association with spontaneous abortion and congenital malformations 1:

• Use only topical azole therapy for 7 days 1
• Longer courses (7 days minimum) are necessary as shorter regimens are less effective in pregnancy 1

HIV-Positive Patients

Treatment regimens should be identical to HIV-negative women, with equivalent response rates expected 1

Over-the-Counter Self-Treatment

Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of identical symptoms 3, 1:

• Any woman whose symptoms persist after OTC treatment must seek medical evaluation 1
• Any woman with recurrence within 2 months requires medical assessment to rule out resistant organisms, non-albicans species, or alternative diagnoses 1
• Self-diagnosis of yeast vaginitis is unreliable; microscopic confirmation should be obtained before treatment 1

Common Pitfalls to Avoid

Do not treat asymptomatic colonization, as this represents normal vaginal flora, not infection 3, 1

Do not use single-dose treatments for complicated VVC—reserve these only for uncomplicated mild-to-moderate cases 1

Maintain appropriate clinical suspicion for concurrent sexually transmitted diseases, as VVC can occur simultaneously with STDs 3, 1

Topical azoles are more effective than nystatin, achieving 80-90% symptom relief and negative cultures versus lower rates with nystatin 3, 1