What is the recommended treatment for vulvovaginal yeast infection, including first‑line options, pregnancy considerations, recurrent infection management, and second‑line therapies?

Treatment of Vulvovaginal Yeast Infection

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

Uncomplicated VVC (90% of cases)

Definition: Sporadic or infrequent episodes, mild-to-moderate symptoms, likely Candida albicans, in immunocompetent women 2

First-Line Treatment Options

Topical azoles (choose based on patient preference and cost):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 3
• Miconazole 2% cream 5g intravaginally for 7 days 1, 3
• Terconazole 0.4% cream 5g intravaginally for 7 days 3
• Terconazole 0.8% cream 5g intravaginally for 3 days 3
• Single-dose options: Clotrimazole 500mg vaginal tablet or tioconazole 6.5% ointment 3

Oral therapy:

• Fluconazole 150 mg single oral dose 1, 3

All regimens achieve 80-90% symptom relief and negative cultures 2, 1

Critical Caveat

Oil-based vaginal creams and suppositories weaken latex condoms and diaphragms—patients must use alternative contraception during treatment 1, 3

Complicated VVC (10% of cases)

Definition: Severe symptoms, recurrent (≥4 episodes/year), non-albicans species, pregnancy, diabetes, immunosuppression, or debilitation 2

Severe VVC

Extended therapy required:

• Topical azole for 7-14 days 1
• OR Fluconazole 150 mg oral, repeated after 72 hours (two doses total) 1

Recurrent VVC (≥4 episodes/year)

Induction phase:

• Topical azole for 7-14 days OR fluconazole 150 mg repeated 3 days later 1
• Obtain vaginal cultures to confirm diagnosis and identify non-albicans species 1

Maintenance phase (after achieving mycologic remission):

• Fluconazole 100-150 mg weekly for 6 months (first-line, improves quality of life in 96% of women) 1, 4
• Alternative: Clotrimazole 500 mg vaginal suppositories weekly 1
• Alternative: Itraconazole 400 mg monthly or 100 mg daily for 6 months 1

Critical reality check: 30-40% of women experience recurrence after stopping maintenance therapy—set realistic expectations 1

Non-Albicans VVC (C. glabrata, C. krusei)

• 7-14 days of non-fluconazole azole therapy (terconazole preferred due to better activity against non-albicans species) 1
• For persistent non-albicans recurrence: Nystatin 100,000 units daily via vaginal suppositories 1
• Boric acid 600 mg vaginal capsule daily for 14 days is effective for azole-resistant non-albicans species 2

Pregnancy

Only topical azole therapies for 7 days—oral azoles are contraindicated 2, 1

Acceptable options:

• Clotrimazole 1% cream for 7 days 1
• Miconazole 2% cream for 7 days 1
• Terconazole 0.4% cream for 7 days 1

VVC commonly occurs during pregnancy and requires the full 7-day course for adequate treatment 2

HIV/Immunocompromised Patients

• Use same regimens as immunocompetent patients but extend duration to 7-14 days 2, 1
• No difference in treatment approach for HIV-infected women, but longer courses improve outcomes 2

Follow-Up and Partner Treatment

• Patients return only if symptoms persist or recur within 2 months 2, 1
• Partner treatment is NOT routinely recommended but may be considered in recurrent cases 2, 1
• VVC is not sexually transmitted 2

Common Pitfalls to Avoid

Self-diagnosis is unreliable: Inappropriate self-treatment with OTC products delays proper diagnosis of other vulvovaginitis causes (bacterial vaginosis, trichomoniasis, contact dermatitis) 1

Do not treat asymptomatic colonization: 10-20% of women normally harbor Candida without symptoms—treatment is only indicated when symptomatic 1, 3

Resistance testing considerations: For recurrent cases, antifungal susceptibility testing should be performed at vaginal pH 4 (not standard laboratory pH 7), as MICs are 388-fold higher at vaginal pH 4, revealing clinically significant resistance 1

Biofilm formation: Contributes to treatment failure and persistence in recurrent cases, supporting the need for extended therapy 1