What is the recommended treatment for uncomplicated vulvovaginal candidiasis in an otherwise healthy adult woman?

Treatment of Uncomplicated Vulvovaginal Candidiasis

For uncomplicated vaginal yeast infections in healthy adult women, either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days) are equally effective first-line treatments, with both achieving 80-90% cure rates. 1

First-Line Treatment Options

You have two equally effective choices:

Option 1: Oral Fluconazole (Most Convenient)

• Single 150 mg oral dose 1, 2
• Achieves clinical cure or improvement in 94% of patients at 14 days 3
• Provides faster symptom relief compared to topical agents 4
• More convenient for patients who prefer to avoid intravaginal application 3

Option 2: Topical Azole Therapy

• No single topical agent is superior to another 1
• Common regimens include:
  • Clotrimazole 1% cream for 7-14 days 5
  • Clotrimazole 100 mg vaginal tablet for 7 days 5
  • Miconazole 2% cream for 7 days 5
  • Terconazole 0.4% cream for 7 days 5
• Short-course therapy (1-3 days) achieves similar efficacy to longer courses for uncomplicated cases 5

When to Escalate Treatment

Severe Acute VVC

Use fluconazole 150 mg every 72 hours for 2-3 total doses (not just one dose) 1

Recurrent VVC (≥4 Episodes Per Year)

This affects less than 5% of women and requires a two-phase approach: 5

1. Induction Phase: 10-14 days of topical azole OR fluconazole 150 mg repeated after 3 days 1, 5
2. Maintenance Phase: Fluconazole 150 mg weekly for 6 months 1, 6
   • This improves quality of life in 96% of women 5
   • However, 30-40% will experience recurrence after stopping maintenance 5, 6

Non-Albicans Species (C. glabrata)

If standard azole therapy fails:

• Intravaginal boric acid 600 mg daily for 14 days 1
• Alternative: Nystatin suppositories 100,000 units daily for 14 days 1
• Obtain vaginal cultures to confirm species and guide therapy 5

Critical Diagnostic Confirmation

Before treating, confirm the diagnosis with: 1

• Wet mount with 10% KOH showing yeast or pseudohyphae
• Vaginal pH <4.5 (normal pH distinguishes VVC from bacterial vaginosis)
• Clinical symptoms: pruritus, white discharge, vulvar erythema, dyspareunia

Do not treat asymptomatic colonization—10-20% of women normally harbor Candida without symptoms 5

Special Population: Pregnancy

Only topical azole therapy for 7 days is recommended in pregnancy—oral fluconazole is contraindicated 7

• Use clotrimazole, miconazole, or terconazole intravaginally 7
• Seven-day regimens are more effective than shorter courses in pregnancy 7

Important Caveats

• Oil-based vaginal creams and suppositories weaken latex condoms and diaphragms—counsel patients on alternative contraception during treatment 5
• Partner treatment is not routinely recommended unless the partner has symptomatic balanitis 5
• Patients with recurrent infections have significantly lower cure rates (33% vs 66% in those without recurrence history) 3
• Self-diagnosis and over-the-counter treatment can delay proper diagnosis of other vulvovaginal conditions 5

Follow-Up

Patients should return only if symptoms persist or recur within 2 months 5. For recurrent cases, obtain vaginal cultures to identify unusual species or azole resistance 5.