How should vulvovaginal candidiasis with painful fissures be treated?

Treatment of Vulvovaginal Candidiasis with Fissures

For vulvovaginal candidiasis presenting with painful fissures, extend topical azole therapy to 7–14 days rather than using single-dose oral fluconazole, because severe vulvar inflammation with tissue breakdown requires prolonged treatment duration. 1

Why Fissures Change the Treatment Approach

• Fissures indicate severe vulvar inflammation with tissue breakdown, which classifies the infection as complicated vulvovaginal candidiasis requiring extended therapy rather than standard 1–3 day regimens. 1
• Short-course treatments (single-dose fluconazole or 1–3 day topical regimens) are inappropriate when marked vulvar erythema, edema, excoriation, or fissure formation is present. 1, 2
• The presence of fissures signals that both vaginal and vulvar tissues are severely affected, necessitating longer contact time with antifungal agents. 1

Recommended Treatment Regimen

Primary therapy:

• Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days, OR 1
• Miconazole 2% cream 5 g intravaginally daily for 7 days, OR 1
• Terconazole 0.4% cream 5 g intravaginally daily for 7 days 1

Alternative if azole failure suspected (non-albicans species):

• Boric acid 600 mg vaginal capsule daily for 14 days if symptoms persist after appropriate azole therapy, as this suggests Candida glabrata infection. 2, 3

Symptomatic Relief for Fissures

• Apply topical lidocaine directly to fissures for persistent introital pain. 1
• Use water-based lubricants during any genital contact to prevent further trauma. 1
• Apply vaginal moisturizers 3–5 times per week to the vagina, introitus, and external vulvar folds to promote healing. 1

Critical Pitfalls to Avoid

• Do not use oral fluconazole 150 mg single dose for severe disease with fissures; systemic therapy does not provide adequate duration of mucosal contact for severe inflammation. 1, 2
• Do not use 1–3 day topical regimens when tissue breakdown is present; these require minimum 7–14 day courses. 1, 2
• Do not assume all cases are Candida albicans; if symptoms persist after 7–14 days of appropriate azole therapy, obtain vaginal culture to identify non-albicans species (especially C. glabrata), which require boric acid treatment. 2, 3
• Do not treat empirically without microscopic confirmation; self-diagnosis is accurate in only 30–50% of cases, and alternative diagnoses (bacterial vaginosis, trichomoniasis, contact dermatitis) require different management. 1

When to Suspect Azole-Resistant Infection

If fissures and symptoms persist despite 7–14 days of topical azole therapy:

• Switch to boric acid 600 mg intravaginally daily for 14 days as first-line therapy for suspected C. glabrata. 2, 3
• Continue applying topical azole cream (clotrimazole 1% or miconazole 2%) to perineal and vulvar skin twice daily for 7–14 days to treat cutaneous extension. 2
• Consider referral for topical 17% flucytosine cream alone or combined with 3% amphotericin B cream after specialist consultation (weak recommendation). 2

Follow-Up Recommendations

• Instruct patients to return if symptoms persist after completing the full 7–14 day course or if recurrence occurs within 2 months. 1, 2
• If ≥3 episodes occur within 12 months (meeting recurrent vulvovaginal candidiasis criteria), initiate induction therapy for 10–14 days followed by maintenance fluconazole 150 mg weekly for 6 months. 1, 3

Special Considerations

• In pregnancy: Use only topical azole therapy for 7 days; avoid oral fluconazole due to association with spontaneous abortion and congenital malformations. 1, 3
• In diabetes or immunosuppression: Optimize underlying conditions because these patients typically require the full 14-day treatment duration. 2
• Partner treatment: Not routinely required unless male partner develops symptomatic balanitis. 2