What is the treatment for vaginal candidiasis in a female of reproductive age?

Treatment of Vaginal Candidiasis in Reproductive-Age Women

For uncomplicated vaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole OR a short-course topical azole (1-7 days), both achieving 80-90% cure rates. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by:

• Clinical presentation: Pruritus, erythema in vulvovaginal area, white discharge 1
• Laboratory confirmation: Either wet prep/Gram stain showing yeasts or pseudohyphae, OR positive culture for yeast species 1
• Vaginal pH: Should be ≤4.5 (normal) 1
• Important caveat: 10-20% of asymptomatic women harbor Candida—do NOT treat positive cultures without symptoms 1

Treatment Regimens by Disease Severity

Uncomplicated VVC (Mild-to-Moderate, Sporadic, Non-Recurrent)

Oral Option:

• Fluconazole 150 mg single oral dose 1
  • Achieves 55% therapeutic cure (clinical + mycologic) 2
  • More gastrointestinal side effects than topical agents (16% vs 4%) 2

Topical Options (Choose One):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Clotrimazole 500 mg vaginal tablet, single application 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Miconazole 200 mg suppository for 3 days 1
• Terconazole 0.8% cream 5g intravaginally for 3 days 1

Key Point: Topical azoles are more effective than nystatin and achieve 80-90% symptom relief with negative cultures 1

Complicated VVC (Severe, Recurrent, Non-albicans Species, or Abnormal Host)

For Severe Vaginitis:

• Fluconazole 150 mg on Day 1 and Day 4 (two sequential doses) 3
  • Superior clinical cure rates compared to single dose (P=0.015) 3
  • Alternatively: 7-14 days of topical azole therapy 1

For Recurrent VVC (≥4 Episodes/Year):

Initial Treatment Phase:

• Longer duration therapy: 7-14 days topical azole OR fluconazole 150 mg repeated 3 days later 1

Maintenance Phase (After Achieving Remission):

• Fluconazole 100-150 mg once weekly for 6 months 1, 4
• Alternative: Clotrimazole 500 mg vaginal suppository once weekly 1
• Critical caveat: 30-40% will have recurrent disease once maintenance therapy is discontinued 1

Special Populations

Pregnancy:

• Only topical azole therapies should be used 1
• Recommend 7-day courses during pregnancy 1
• Most studied agents: clotrimazole, miconazole, butoconazole, terconazole 1

HIV-Infected Women:

• Treat with same regimens as HIV-negative women 1
• May experience more frequent and severe episodes 1

Over-the-Counter (OTC) Considerations

OTC preparations (butoconazole, clotrimazole, miconazole, tioconazole) are available 1

• Only recommend for: Women previously diagnosed with VVC who have recurrence of identical symptoms 1
• Seek medical care if: Symptoms persist after OTC use OR recurrence within 2 months 1
• Common pitfall: Inappropriate OTC use delays diagnosis of other vulvovaginitis etiologies 1

Non-albicans Candida Species

Important consideration: 10-20% of recurrent VVC is caused by non-albicans species (especially C. glabrata) 1

• These species respond poorly to conventional azole therapy 1
• Obtain vaginal cultures in recurrent cases to identify species 1
• Multivariate analysis shows non-albicans infection predicts significantly reduced clinical and mycologic response regardless of therapy duration 3

Follow-Up

• No routine follow-up needed if asymptomatic after treatment 1
• Return only if symptoms persist or recur within 2 months 1
• Women with ≥3 episodes/year should be evaluated for predisposing conditions 1

Partner Management

Sex partner treatment is NOT routinely recommended 1

• VVC is not sexually transmitted 1
• Exception: Male partners with symptomatic balanitis may benefit from topical antifungal treatment 1

Important Drug Interactions

Oral fluconazole may interact with: terfenadine, astemizole, calcium channel antagonists, warfarin, cyclosporine, phenytoin, protease inhibitors, oral hypoglycemics 1, 2