What treatment options are available for an adult female with a vaginal yeast infection?

Treatment Options for Vaginal Yeast Infections

For uncomplicated vaginal yeast infections, prescribe either a single 150 mg oral fluconazole tablet or a short-course topical azole (1-3 days), both achieving 80-90% cure rates. 1, 2

First-Line Treatment Choices

You have two equally effective options for uncomplicated cases:

Oral Therapy (Most Convenient)

• Fluconazole 150 mg as a single oral dose 1, 2
• This achieves clinical cure in 80-90% of patients within 5-16 days 3
• Preferred by approximately half of patients over topical therapy 4

Topical Therapy (Preferred in Pregnancy)

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

• Clotrimazole 500 mg vaginal tablet, single application 1, 2
• Miconazole 200 mg vaginal suppository daily for 3 days 1, 2
• Terconazole 0.8% cream 5g intravaginally for 3 days 1, 2
• Tioconazole 6.5% ointment 5g intravaginally, single application 1, 2

Critical caveat: All topical creams and suppositories are oil-based and may weaken latex condoms and diaphragms 1, 2, 5

When to Use Extended Therapy (7+ Days)

Prescribe longer courses for complicated cases, which include: 1, 2

• Severe symptoms (extensive vulvar erythema, edema, excoriation, fissure formation)
• Recurrent infections (≥3 episodes in 12 months) 1
• Non-albicans Candida species (especially C. glabrata)
• Immunocompromised patients (diabetes, HIV, corticosteroid use)
• Pregnancy 2

For these patients, use:

• Topical azole for 7-14 days (e.g., clotrimazole 1% cream 5g intravaginally for 7-14 days) 1
• Pregnant women must receive only topical azoles for 7 days (oral fluconazole is contraindicated) 2

Recurrent Vulvovaginal Candidiasis (≥3 Episodes/Year)

This affects approximately 9% of women and requires a two-phase approach: 1, 2

Induction Phase:

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

Maintenance Phase:

• Fluconazole 150 mg orally once weekly for at least 6 months 1, 2
• Despite this regimen, 63% of women experience recurrence after completing maintenance therapy 1
• Maintenance therapy improves quality of life in 96% of women 1

Important consideration: pH testing at vaginal pH 4 (rather than laboratory standard pH 7) reveals clinically significant azole resistance, particularly with terconazole against C. glabrata (388-fold higher MIC at pH 4) 1

Resistant or Non-Albicans Infections

For C. glabrata or azole-resistant cases: 1, 2

• Boric acid 600 mg gelatin capsules intravaginally daily for 14 days 1, 2
• Topical nystatin 100,000 units daily for 14 days 1

Confirming the Diagnosis Before Treatment

Do not treat empirically without confirmation. 2 Self-diagnosis is unreliable and leads to overuse of antifungals with subsequent contact dermatitis 1

Required diagnostic criteria: 1, 2

• Vaginal pH <4.5 (normal) 1, 2
• Plus either wet mount (10% KOH or saline) showing yeasts/pseudohyphae or positive culture 1, 2
• 10-20% of asymptomatic women harbor Candida; positive culture without symptoms does not warrant treatment 1

Partner Management

Do not treat sexual partners routinely — vulvovaginal candidiasis is not sexually transmitted 2

Exception: Male partners with symptomatic balanitis may benefit from topical antifungal treatment 2

Patient Instructions for Optimal Results

Counsel patients to: 5

• Continue treatment during menstrual periods (use pads, not tampons) 5
• Avoid douches, tampons, and spermicides during treatment 5
• Avoid vaginal intercourse while using topical products 5
• Wear cotton underwear and loose-fitting clothes 5
• Change out of wet bathing suits or damp clothes promptly 5

Over-the-Counter Considerations

Advise self-treatment only for women with previously diagnosed VVC who have recurrence of identical symptoms 2

Women using OTC preparations must seek medical evaluation if: 2

• Symptoms persist after treatment
• Symptoms recur within 2 months

When to Suspect Something Other Than Simple Yeast Infection

Refer for further evaluation if patient has: 1

• Lower abdominal, back, or shoulder pain
• Fever, chills, nausea, vomiting
• Foul-smelling vaginal discharge (suggests bacterial vaginosis or STI)
• Frequent infections (≥3 in 6 months) requiring evaluation for diabetes, HIV, or other immunosuppression 1