What is the first‑line treatment for uncomplicated vaginal candidiasis, and what alternatives are recommended for recurrent infection, pregnancy, or refractory cases?

Treatment of Vaginal Candidiasis

Azole antifungals—either topical intravaginal formulations or oral fluconazole 150 mg as a single dose—remain the first-line treatment for uncomplicated vaginal candidiasis, with both routes achieving >90% clinical cure rates. 1

Uncomplicated Vulvovaginal Candidiasis

For mild-to-moderate infections in immunocompetent women with sporadic episodes, treatment options include:

Topical Intravaginal Azoles (equally effective):

• Clotrimazole 1% cream 5g for 7-14 days 2
• Clotrimazole 100 mg vaginal tablet daily for 7 days 2
• Clotrimazole 500 mg vaginal tablet as single application 2
• Miconazole 2% cream 5g for 7 days 1, 2
• Terconazole 0.4% cream 5g for 7 days 1, 2
• Butoconazole 2% cream 5g for 3 days 1, 2

Oral Alternative:

• Fluconazole 150 mg single oral dose 1, 2

Both topical and oral azoles demonstrate equivalent efficacy (80-90% cure rates), so the choice depends on patient preference, cost considerations, and potential drug interactions. 3 Oral fluconazole may interact with calcium channel blockers, warfarin, and protease inhibitors. 2 Topical agents rarely cause systemic effects but may produce local burning or irritation. 2

Recurrent Vulvovaginal Candidiasis (RVVC)

For women with ≥3 symptomatic episodes within 12 months, initiate induction therapy followed by maintenance suppression. 1

Induction Phase:

• Fluconazole 150 mg every 72 hours for 2-3 doses 2, 4
• OR topical azole therapy for 7-14 days 2

Maintenance Phase:

• Fluconazole 150 mg weekly for 6 months 2, 4

This maintenance regimen improves quality of life in 96% of women, though recurrence rates of 40-63% occur after discontinuation. 4 Patients should be counseled about this high recurrence risk and the potential need for retreatment. 2

Pregnancy

Oral fluconazole is contraindicated in pregnancy due to associations with spontaneous abortion, craniofacial defects, and cardiac malformations. 1, 4

Recommended Treatment:

• Topical azole therapy for 7 days 4

Longer treatment courses are necessary in pregnancy as shorter regimens show reduced efficacy. 4

Non-albicans Candida Species (Refractory Cases)

When C. glabrata or other non-albicans species are suspected (particularly after failed azole therapy or confirmed by culture):

• Boric acid 600 mg intravaginal gelatin capsule daily for 14 days 2, 4
• OR nystatin 100,000-unit intravaginal suppository daily for 14 days 2
• OR 17% flucytosine cream ± 3% amphotericin B cream for 14 days 2, 4

Boric acid appears most useful for symptomatic non-albicans infections. 1 These species are frequently dose-dependent susceptible or resistant to fluconazole. 5

Critical Diagnostic Considerations

Laboratory confirmation is essential before treatment, especially for recurrent cases, as symptoms are nonspecific. 4

• Vaginal pH should be ≤4.5 (higher pH suggests bacterial vaginosis or trichomoniasis) 2, 4
• Wet mount with 10% KOH to visualize yeast/pseudohyphae 2
• Culture for negative microscopy or suspected non-albicans species 1, 2
• PCR testing shows superior sensitivity (90.7%) and specificity (93.6%) compared to clinical diagnosis 1

Common Pitfalls to Avoid

Do not rely on clinical diagnosis alone—less than 50% of women treated for VVC have objective diagnostic confirmation. 1 This leads to unnecessary treatment and missed alternative diagnoses.

Avoid probiotics and alternative therapies (honey-based ointments, essential oils) as they show equal or inferior results to FDA-approved medications and lack regulation. 1, 4

Do not use identical treatment duration for complicated and uncomplicated cases—complicated VVC requires extended therapy (7-14 days minimum). 4

Follow-up Protocol

Reevaluate with culture if symptoms persist after treatment to confirm diagnosis and identify potentially resistant species. 2 For women on maintenance therapy for RVVC, monitor for recurrence after the 6-month course, as relapse is common. 4

HIV-positive women should receive identical treatment regimens as HIV-negative women, with equivalent expected response rates. 4