What is the first‑line therapy for uncomplicated vulvovaginal candidiasis in an otherwise healthy elderly woman?

First-Line Treatment for Vulvovaginal Candidiasis in the Elderly

A single oral dose of fluconazole 150 mg is the first-line treatment for uncomplicated vulvovaginal candidiasis in an otherwise healthy elderly woman, achieving >90% clinical response rates. 1

Confirm the Diagnosis Before Treatment

Before prescribing any antifungal therapy, confirm the diagnosis to avoid treating asymptomatic colonization (present in 10-20% of women) 1:

• Perform wet mount preparation with 10% potassium hydroxide to visualize yeast or pseudohyphae 1
• Measure vaginal pH, which should be ≤4.5 for candidiasis 1
• Obtain vaginal culture if wet mount is negative but symptoms persist 1

Symptoms alone (pruritus, discharge, dysuria, dyspareunia) are nonspecific and insufficient for diagnosis. 1

Treatment Algorithm for Uncomplicated Disease

First-Line: Single-Dose Oral Fluconazole

Fluconazole 150 mg orally as a single dose is the preferred regimen 1, 2:

• Achieves 80-90% clinical cure rates and 60-77% mycologic eradication 1
• Provides efficacy equivalent to multi-day topical azole therapy with superior convenience 1
• FDA-approved and designated as first-line therapy by the Infectious Diseases Society of America 1

Alternative: Short-Course Topical Azoles

If oral therapy is contraindicated or patient-preferred, use topical azoles for 1-3 days 1, 2:

• Clotrimazole 500 mg intravaginal tablet (single application) 1
• Miconazole 200 mg suppository once daily for 3 days 1
• Terconazole 0.8% cream 5 g intravaginally for 3 days 1

These achieve comparable 80-90% clinical cure rates to fluconazole 1

When Single-Dose Therapy Is NOT Appropriate

Complicated Disease Requires Extended Therapy

Do not use single-dose fluconazole if any of the following are present 1, 3:

• Severe disease (extensive vulvar erythema, edema, excoriation, or fissures): Use fluconazole 150 mg every 72 hours for 3 doses (total 450 mg over 6 days) or topical azole for 7-14 days 3
• Recurrent infection (≥4 episodes per year): Requires induction therapy (fluconazole 150 mg every 72 hours for 3 doses) followed by maintenance therapy (fluconazole 150 mg weekly for 6 months) 1, 3
• Suspected non-albicans species (prior azole exposure or treatment failure): Consider boric acid 600 mg intravaginal capsule daily for 14 days for C. glabrata 1, 3
• Immunocompromised hosts (uncontrolled diabetes, HIV, corticosteroid use): Use extended therapy regimens 3, 2

Critical Drug Interactions in Elderly Patients

Fluconazole has significant drug interactions particularly relevant in elderly populations 1:

• Warfarin: Elevates INR and increases bleeding risk—monitor INR closely 1
• Oral hypoglycemics: May cause hypoglycemia—monitor blood glucose 1
• Phenytoin: Risk of phenytoin toxicity 1
• Calcium-channel blockers: Potential for enhanced effects 1
• Calcineurin inhibitors (tacrolimus/cyclosporine): Increased immunosuppressant levels 1

Baseline liver tests are not required for single-dose therapy in patients without known hepatic disease 1

Follow-Up and Treatment Failure

• Clinical cure or improvement should be evident within 5-7 days 1
• If symptoms persist beyond 5-7 days or recur within 2 months, re-evaluate with repeat cultures to identify non-albicans species 1
• Treatment failure suggests possible C. glabrata or C. krusei, which may require boric acid or nystatin 1

Age-Specific Considerations

There is no need to adjust the standard 150 mg fluconazole dose in elderly patients. 1 The pharmacokinetics in healthy elderly women are similar to younger adults, and the same single-dose regimen achieves equivalent efficacy and safety profiles 4, 5, 6. The elderly may have higher rates of polypharmacy, making drug interaction screening essential before prescribing fluconazole 1.

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization—10-20% of women harbor Candida without infection 1
• Do not rely on self-diagnosis—it is unreliable and leads to excessive antifungal use 2
• Do not use single-dose therapy for complicated disease—reserve it only for uncomplicated mild-to-moderate infections 3
• Do not prescribe without diagnostic confirmation—symptoms are nonspecific and can result from multiple infectious and noninfectious causes 1