What is the recommended treatment for a non-pregnant woman with vaginal candidiasis, considering her medical history and potential allergies or sensitivities to antifungal medications?

Suppository Treatment for Vaginal Candidiasis

For non-pregnant women with uncomplicated vaginal candidiasis, intravaginal suppositories are equally effective as oral fluconazole, with miconazole 200 mg suppository daily for 3 days or terconazole 80 mg suppository daily for 3 days being first-line options that achieve >90% response rates. 1

Recommended Suppository Regimens

The following suppository options are endorsed by the Infectious Diseases Society of America for vaginal candidiasis 2:

• Miconazole 100 mg vaginal suppository: 1 suppository daily for 7 days 2
• Miconazole 200 mg vaginal suppository: 1 suppository daily for 3 days 2, 3
• Miconazole 1200 mg vaginal suppository: Single-dose application 2, 3
• Terconazole 80 mg vaginal suppository: 1 suppository daily for 3 days 2

When to Choose Suppositories Over Oral Therapy

Suppositories should be preferred in the following situations:

• Pregnancy: Oral fluconazole is contraindicated due to associations with spontaneous abortion and congenital malformations; only 7-day topical azole therapy should be used 1, 4
• Drug interactions: When patients are taking medications that interact with fluconazole, including warfarin, calcium channel antagonists, or protease inhibitors 4, 3
• Patient preference: Some women prefer topical therapy to avoid systemic medication 1

Treatment Duration Based on Severity

For mild-to-moderate uncomplicated cases: Single-dose or 3-day suppository regimens are appropriate 1, 4

For severe or complicated cases: Extended 7-14 day suppository therapy is required, as single-dose treatments are inadequate 1, 4

Critical Diagnostic Confirmation Before Treatment

Do not treat without microscopic confirmation, as self-diagnosis is incorrect in the majority of cases 1:

• Perform wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae 1, 4
• Verify normal vaginal pH (≤4.5) to exclude bacterial vaginosis or trichomoniasis 1, 4
• Obtain vaginal cultures if microscopy is negative but clinical suspicion remains high 4

Instructions for Optimal Suppository Use

During treatment, patients must 3:

• Continue therapy even during menstrual periods 3
• Avoid tampons, as they remove medication from the vagina; use deodorant-free pads instead 3
• Avoid douches, which wash medication out 3
• Avoid spermicides, which interfere with the medication 3
• Abstain from vaginal intercourse during treatment 3
• Note that condoms and diaphragms may be damaged by the suppository and fail 3

Recurrent Vulvovaginal Candidiasis Protocol

For women with ≥4 episodes per year, a two-phase approach is mandatory 1, 4:

1. Induction phase: 10-14 days of topical suppository therapy 4
2. Maintenance phase: Oral fluconazole 150 mg weekly for 6 months (suppositories are not used for maintenance) 1, 4

This achieves control in >90% of patients, though 40-50% will experience recurrence after cessation 1, 4

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida without infection 4
• Do not reserve single-dose suppositories for severe cases; they are only appropriate for mild-to-moderate uncomplicated infections 1, 4
• Do not assume treatment failure is due to resistance without first confirming medication adherence, ruling out reinfection, and considering non-albicans species 1
• Do not overlook concurrent sexually transmitted infections, which can coexist with candidiasis 4, 3

When Suppositories Are Less Effective

Non-albicans Candida species (particularly C. glabrata) are less responsive to standard azole suppositories 4. For these cases, boric acid 600 mg intravaginal capsules daily for 14 days is first-line therapy 4.

Follow-Up Recommendations

Follow-up is only necessary if 1:

• Symptoms persist after completing therapy
• Symptoms recur within 2 months
• Patient has recurrent infections requiring maintenance therapy

When symptoms persist, consider alternative diagnoses, resistant organisms, non-albicans species, or the need for extended therapy 1.