Treatment for Vaginal Candidiasis
First-Line Treatment for Uncomplicated Vulvovaginal Candidiasis
For non-pregnant women with uncomplicated vulvovaginal candidiasis, prescribe a single oral dose of fluconazole 150 mg, which achieves >90% clinical cure rates and provides faster symptom relief than topical alternatives. 1
Alternative First-Line Options
Topical azole therapy is equally effective if oral therapy is contraindicated or patient-preferred, with options including: 1, 2
Both oral fluconazole and short-course topical azoles achieve 80-90% clinical cure rates and 60-77% mycologic eradication rates. 1
Diagnostic Confirmation Before Treatment
Always confirm the diagnosis before prescribing antifungal therapy, as self-diagnosis is unreliable and symptoms are nonspecific. 1, 2
- Perform wet-mount microscopy with 10% KOH to visualize yeast or pseudohyphae 1, 2
- Verify vaginal pH ≤4.5 (elevated pH suggests bacterial vaginosis or trichomoniasis) 1, 2
- Obtain vaginal culture if wet-mount is negative but symptoms persist 1
- Do not treat asymptomatic colonization, as 10-20% of women harbor Candida species without infection 1, 2
Treatment for Pregnant Patients
Pregnant women must receive only topical azole therapy for 7 days; oral fluconazole is contraindicated due to associations with spontaneous abortion and congenital malformations. 2, 3
Recommended Regimens for Pregnancy
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
- Clotrimazole 100mg vaginal tablet daily for 7 days 3
- Miconazole 2% cream 5g intravaginally for 7 days 3
- Terconazole 0.4% cream 5g intravaginally for 7 days 3
Seven-day regimens are more effective than shorter courses during pregnancy. 3
Complicated Vulvovaginal Candidiasis
For severe disease (extensive vulvar erythema, edema, excoriation, or fissures), prescribe fluconazole 150 mg every 72 hours for 3 doses (total 450 mg over 6 days) or topical azole therapy for 7-14 days. 1, 2
When to Suspect Complicated Disease
- Severe symptoms with marked vulvar inflammation 1
- Recurrent episodes (≥4 per year) 1, 2
- Non-albicans Candida species (especially C. glabrata) 1, 2
- Immunocompromised hosts (HIV, uncontrolled diabetes, immunosuppression) 1, 2
Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)
For recurrent disease, use a two-phase approach: induction therapy followed by 6-month maintenance suppression. 1, 2
Treatment Protocol
- Induction phase: Fluconazole 150 mg every 72 hours for 3 doses OR topical azole for 10-14 days 1, 2
- Maintenance phase: Fluconazole 150 mg orally weekly for 6 months 1, 2
- Maintenance therapy achieves symptom control in >90% of patients 2
- Expect 40-50% recurrence after stopping maintenance therapy 2
Treatment Failure and Non-Albicans Species
If symptoms persist after appropriate therapy, obtain vaginal culture to identify non-albicans species, particularly C. glabrata. 1, 2
- Boric acid 600 mg vaginal capsule daily for 14 days is first-line for non-albicans species 2
- Non-albicans Candida are less responsive to standard azole therapy 2
Critical Safety Considerations
Drug Interactions with Fluconazole
Verify potential interactions before prescribing oral fluconazole: 1, 2
- Warfarin (elevated INR and bleeding risk) 1
- Oral hypoglycemics (hypoglycemia) 1
- Phenytoin (toxicity) 1
- Calcium-channel blockers, protease inhibitors, calcineurin inhibitors 1
Adverse Effects
- Oral fluconazole may cause nausea, abdominal pain, and headache 2
- Topical agents rarely cause systemic effects but may produce local burning or irritation 2
Common Pitfalls to Avoid
- Never prescribe single-dose therapy for severe symptoms or recurrent disease—these require extended treatment 2
- Do not treat partners routinely, as vulvovaginal candidiasis is not sexually transmitted (treat only if symptomatic balanitis present) 3
- Avoid nystatin as first-line therapy—topical azoles achieve 80-90% cure rates versus lower efficacy with nystatin 2, 3
- Reserve self-treatment with OTC preparations only for women with previously confirmed diagnosis experiencing identical recurrent symptoms 2
Follow-Up Recommendations
- Clinical cure or improvement should occur within 5-16 days 1
- Re-evaluate only if symptoms persist after treatment or recur within 2 months 1, 2
- Repeat cultures are indicated for treatment failure to guide alternative therapy 1
- Seek immediate evaluation if fever, chills, or lower abdominal pain develop, suggesting possible pelvic infection 2