What is the recommended treatment for a patient with vaginal candidiasis, considering their medical history and potential risk factors?

Treatment of Vaginal Candidiasis

For uncomplicated vaginal candidiasis, treat with a single oral dose of fluconazole 150 mg, which achieves >90% clinical cure rates and is equivalent to topical azole therapy. 1

Classification and Diagnosis

Before initiating treatment, classify the infection as uncomplicated (90% of cases) or complicated (10% of cases) based on these criteria: 1

Uncomplicated vulvovaginal candidiasis:

• Mild-to-moderate symptoms
• Sporadic occurrence (not recurrent)
• Likely Candida albicans
• Non-immunocompromised host 1

Complicated vulvovaginal candidiasis includes: 1

• Severe symptoms (extensive vulvar erythema, edema, excoriation, fissures)
• Recurrent infection (≥4 episodes per year)
• Non-albicans Candida species (C. glabrata, C. krusei)
• Uncontrolled diabetes, immunosuppression, or pregnancy

Confirm diagnosis before treatment with wet mount preparation using 10% potassium hydroxide to demonstrate yeast/hyphae and check vaginal pH (should be 4.0-4.5). 1 If wet mount is negative but clinical suspicion remains high, obtain vaginal cultures for Candida. 1

Treatment Regimens

Uncomplicated Vulvovaginal Candidiasis

First-line options (equally effective): 1

• Fluconazole 150 mg oral single dose (most convenient) 1, 2
• Any topical azole agent (clotrimazole, miconazole, butoconazole, tioconazole, terconazole) for 1-7 days 1

Both oral and topical formulations achieve entirely equivalent results with >90% response rates. 1 Single-dose fluconazole provides more rapid symptom relief compared to topical agents. 3

Complicated Vulvovaginal Candidiasis

For severe acute disease: 1, 2

• Fluconazole 150 mg every 72 hours for 3 doses (total of 2-3 doses), OR
• Topical azole therapy for 5-7 days 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

Two-phase approach required: 1, 2

Induction phase:

• Topical azole OR oral fluconazole for 10-14 days 1, 2

Maintenance phase:

• Fluconazole 150 mg orally once weekly for 6 months 1, 2
• This achieves symptom control in >90% of patients 1
• Alternative: Clotrimazole 200 mg intravaginally twice weekly OR clotrimazole 500 mg suppository once weekly 1

Important caveat: After stopping maintenance therapy, expect 40-50% recurrence rate. 1 Consider checking for contributing factors like uncontrolled diabetes, though these are rarely found. 1

Non-Albicans Species Management

Candida glabrata (Fluconazole-Resistant)

First determine if true infection versus colonization. 1 If treatment indicated: 1, 2

• Boric acid 600 mg intravaginal gelatin capsules daily for 14 days (must be compounded by pharmacist) 1, 2
• Alternative: Nystatin 100,000 units intravaginal suppositories daily for 14 days 1, 2
• Alternative: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days (requires compounding) 1, 2

Azole therapy, including voriconazole, is frequently unsuccessful for C. glabrata. 1

Candida krusei

Responds to all topical antifungal agents but is intrinsically fluconazole-resistant. 1 Use topical azole therapy for 5-7 days. 1

Special Populations

HIV-infected patients: Treatment should not differ based on HIV status; identical response rates are expected for HIV-positive and HIV-negative women. 1

Safety Profile

Fluconazole 150 mg single dose is well tolerated. 4, 5 In clinical trials for vaginal candidiasis: 4

• Most common side effects: headache (13%), nausea (7%), abdominal pain (6%)
• Most side effects are mild-to-moderate 4
• Serious hepatic reactions are rare and occur primarily in patients with serious underlying conditions taking multiple medications 4

Common Pitfalls to Avoid

• Self-diagnosis without confirmation: Symptoms are nonspecific; always confirm with wet mount or culture before treating. 1, 2
• Undertreating complicated cases: Using single-dose therapy for severe or recurrent disease leads to treatment failure. 1, 2, 6
• Not identifying non-albicans species: C. glabrata and C. krusei require different treatment approaches. 1, 2
• Inadequate follow-up: Patients with recurrent or severe disease require monitoring to ensure response. 2
• Failing to provide maintenance therapy for recurrent cases: Without 6-month maintenance, recurrence rates remain high. 1