What is the recommended first‑line treatment and dosing for vaginal candidiasis in children, including infants, toddlers, and those older than 2 years?

Treatment of Vaginal Candidiasis in Pediatric Patients

First-Line Treatment Recommendation

For pediatric patients with vaginal candidiasis, topical azole antifungals applied intravaginally for 7 days are the recommended first-line therapy, with oral fluconazole reserved for cases where topical therapy is not feasible or has failed. 1, 2

Age-Specific Considerations and Dosing

Topical Therapy (Preferred Initial Approach)

• Clotrimazole 1% cream or 100 mg vaginal tablet applied intravaginally once daily for 7 days is effective and well-tolerated 3
• Miconazole 2% vaginal cream applied intravaginally once daily for 7 days is an equally effective alternative 3
• Topical azoles demonstrate 72-88% mycologic cure rates at short-term assessment 4
• Seven-day courses are as effective as 14-day courses but improve compliance 3

Oral Systemic Therapy (When Topical Fails or Is Not Feasible)

For children ≥2 years requiring systemic therapy:

• Fluconazole 6 mg/kg as a single oral dose (loading dose on day 1) 5, 6
• For children ≥15 years: 150 mg as a single oral dose (adult dosing) 5, 6
• Oral bioavailability exceeds 93%, making oral and IV formulations bioequivalent 5

For infants and toddlers <2 years:

• Fluconazole 5 mg/kg/day has been used safely in this population, though data are limited 7
• Pharmacokinetics differ significantly in neonates (half-life 55-90 hours vs 30 hours in adults), requiring careful dosing 7

When to Escalate to Systemic Therapy

Oral fluconazole should be considered when:

• Topical therapy has failed after adequate trial (7-14 days) 5
• Severe infection with possible deep tissue involvement is suspected 5
• Inadequate topical penetration due to anatomical factors 5
• Patient compliance with topical therapy is not feasible 1

Clinical response should be evident within 7 days of starting oral fluconazole; if no improvement occurs, obtain fungal culture to assess for resistant species 5

Alternative Systemic Options for Refractory Cases

If fluconazole fails or resistance is documented:

• Oral itraconazole solution 2.5 mg/kg twice daily (maximum 200 mg/day) for 14 days 5
• For severe or invasive disease requiring IV therapy:
  • Micafungin 2-4 mg/kg/day IV 7, 5, 8
  • Caspofungin 70 mg/m² loading dose, then 50 mg/m²/day IV 7, 5, 8
  • Liposomal amphotericin B 3 mg/kg/day IV 7, 5, 8

Important Clinical Pitfalls

Before Escalating to Systemic Therapy

Ensure adequate topical therapy has been attempted first:

• Confirm proper application technique 5
• Verify adequate duration (minimum 7 days) 3
• Address hygiene measures and potential reinfection sources 5

Species-Specific Considerations

• Candida krusei is intrinsically resistant to fluconazole and should not be treated with this agent 7
• Candida glabrata exhibits higher MICs to fluconazole, making treatment less reliable 7
• Obtain fungal culture if initial therapy fails to guide species-specific treatment 5

Special Populations

In pregnancy:

• Topical azoles are preferred and may require longer courses (7-14 days) 2
• Oral fluconazole should be avoided during pregnancy 9
• Symptomatic treatment is warranted to prevent complications 2

In neonates and premature infants:

• Amphotericin B deoxycholate 0.5-1 mg/kg/day is better studied than fluconazole in this population 7
• Fluconazole dosing is complicated by immature renal function and prolonged half-life 7

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

• Maintenance therapy with weekly oral fluconazole for up to 6 months enhances treatment success 2
• Topical maintenance with clotrimazole, miconazole, or terconazole 1-3 times weekly is an alternative 9
• Twice-weekly dosing is the most commonly utilized maintenance regimen 9

Treatment Duration and Monitoring

• Continue topical therapy for minimum 7 days even if symptoms resolve earlier 3
• For systemic therapy, single-dose fluconazole is often sufficient for uncomplicated cases 6, 4
• Test of cure is not routinely recommended unless symptoms persist 2
• Ophthalmologic examination is required only for invasive/disseminated candidiasis, not isolated vaginal infection 8