Does Candida vaginitis (vulvovaginal candidiasis) require treatment, and if so, when?

Treatment of Candida Vaginitis

Yes, symptomatic Candida vaginitis requires treatment, but asymptomatic colonization does not. 1

When Treatment Is Indicated

Treat only when symptoms are present and diagnosis is confirmed by microscopy or laboratory testing. The CDC emphasizes that 10–20% of women normally harbor Candida species in the vagina without infection, and asymptomatic colonization does not require therapy even when yeast is visualized on microscopy. 1, 2 Self-diagnosis is unreliable—less than half of patients who self-treat for presumed yeast infection actually have vulvovaginal candidiasis (VVC) on objective testing. 3

Diagnostic Confirmation Before Treatment

• Measure vaginal pH with narrow-range pH paper; VVC typically presents with pH ≤4.5, whereas bacterial vaginosis or trichomoniasis show pH >4.5. 1, 2
• Perform wet-mount microscopy with 10% KOH to visualize budding yeast or pseudohyphae, which are seen in 50–70% of true VVC cases. 3, 1
• Assess clinical signs: thick white "cottage-cheese" discharge, vulvar erythema, intense itching, and absence of malodor strongly favor VVC. 1, 2

The FDA label for terconazole explicitly states that diagnosis should be confirmed by KOH smears and/or cultures before initiating treatment. 4

First-Line Treatment for Uncomplicated VVC

For uncomplicated vulvovaginal candidiasis, either a single 150 mg oral dose of fluconazole OR a short-course (1–7 day) topical azole achieves cure rates exceeding 90%. 1

Oral Option

• Fluconazole 150 mg as a single oral dose is the most convenient regimen. 1

Topical Options (equally effective)

• Clotrimazole 1% cream, 5 g intravaginally daily for 7 days 1
• Miconazole 2% cream, 5 g intravaginally daily for 7 days 1
• Terconazole 0.4% cream, 5 g intravaginally daily for 7 days 1
• Miconazole 200 mg vaginal suppository daily for 3 days 1

All topical azoles and oral fluconazole demonstrate equivalent efficacy for uncomplicated disease. 3, 1

Treatment for Complicated or Severe VVC

When marked vulvar erythema, edema, excoriation, or fissures are present, extend topical azole therapy to 7–14 days rather than using single-dose regimens. 1 Short-course (1–3 day) treatments are inappropriate for severe vulvar inflammation. 1

Alternative regimen for complicated cases: Fluconazole 150 mg every 72 hours for a total of 2–3 doses. 1

Management of Recurrent VVC (≥3 Episodes per Year)

Recurrent vulvovaginal candidiasis (RVVC) is now defined as ≥3 symptomatic episodes within 12 months (previously defined as ≥4 episodes). 3 RVVC affects approximately 9% of women overall, with the highest prevalence (12%) in women aged 25–34 years. 3

Two-Phase Treatment Strategy

Phase 1 (Induction): 10–14 days of topical azole therapy OR oral fluconazole to achieve clinical and mycological remission. 1

Phase 2 (Maintenance): Fluconazole 150 mg orally once weekly for 6 months. 3, 1 This maintenance regimen controls symptoms in >90% of patients during the suppressive period. 1 However, after cessation of the 6-month course, a 40–50% recurrence rate should be anticipated. 3, 1

Special Populations

Pregnancy

Avoid oral fluconazole during pregnancy due to associations with spontaneous abortion and congenital malformations. 1 Use only 7-day topical azole therapy in pregnant women. 1, 2 Notably, vaginal clotrimazole treatment in the first trimester actually reduces the rate of premature births. 5

HIV-Infected Women

Treatment regimens for HIV-positive patients should be identical to HIV-negative women, with equivalent response rates expected. 1, 2

When NOT to Treat

Do not treat asymptomatic colonization. Even when microscopy reveals "few yeast" or occasional Candida organisms, treatment is not indicated in the absence of symptoms. 1, 2 This represents normal vaginal flora variation, not infection. 1

Do not treat sexual partners routinely. VVC is not a sexually transmitted infection, and partner treatment does not reduce recurrence rates. 1, 2 Treat a partner only if he exhibits symptomatic balanitis (erythema and pruritus of the glans). 1, 2

Common Pitfalls to Avoid

• Never treat based on symptoms alone without microscopic confirmation; clinical presentation overlaps significantly with bacterial vaginosis and trichomoniasis. 3, 1
• Do not recommend over-the-counter self-medication unless the patient has a prior confirmed VVC diagnosis and experiences identical recurrent symptoms. 1, 2
• Do not use short-course (1–3 day) regimens for severe vulvar inflammation; these cases require 7–14 day therapy. 1
• Do not assume treatment failure means azole resistance in C. albicans; consider misdiagnosis, non-albicans species (especially C. glabrata), or concurrent bacterial vaginosis. 2, 5

When to Seek Further Evaluation

Patients should return for medical evaluation if:

• Symptoms persist after completing appropriate therapy 1, 2
• Symptoms recur within 2 months 1, 2
• ≥3 episodes occur within a 12-month period (meeting RVVC criteria) 3, 1

For persistent symptoms despite appropriate treatment, obtain vaginal cultures to identify Candida species, as non-albicans species (particularly C. glabrata) account for 10–20% of recurrent cases and show reduced susceptibility to standard azoles. 2, 5 C. glabrata infections may require boric acid 600 mg vaginal capsules daily for 14 days or high-dose fluconazole (800 mg daily for 2–3 weeks). 1, 5