What is the recommended treatment for vaginal candidiasis caused by Candida albicans in non‑pregnant and pregnant adult women, including options for recurrent infection?

Treatment of Vaginal Candida albicans Infection

For uncomplicated vaginal candidiasis caused by Candida albicans, treat with either a single 150 mg oral dose of fluconazole or a short-course (1–7 day) topical azole regimen; both achieve cure rates exceeding 90%. 1

Diagnostic Confirmation Before Treatment

Before initiating therapy, confirm the diagnosis rather than treating empirically based on symptoms alone, because self-diagnosis is accurate in fewer than 50% of cases. 1

• Perform wet-mount microscopy with 10% potassium hydroxide to visualize budding yeast or pseudohyphae. 2, 1
• Measure vaginal pH using narrow-range pH paper; a pH ≤ 4.5 supports candidiasis, whereas pH > 4.5 suggests bacterial vaginosis or trichomoniasis. 1, 3
• Obtain vaginal culture if microscopy is negative but clinical suspicion remains high, or if the patient has recurrent episodes requiring species identification. 2, 1
• Do not treat asymptomatic colonization, as 10–20% of women normally harbor Candida without infection. 1, 3

First-Line Treatment for Uncomplicated Infection

Oral Therapy (Most Convenient)

• Fluconazole 150 mg as a single oral dose is the most convenient first-line option, achieving clinical cure or improvement in 94% of patients at 14 days and therapeutic cure in 77%. 4, 5
• Fluconazole relieves symptoms more rapidly than topical agents and maintains therapeutic vaginal concentrations for several days after a single dose. 6

Topical Therapy (Equally Effective)

If the patient prefers topical treatment or oral therapy is contraindicated, use any of the following regimens 2, 1:

• Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days
• Clotrimazole 2% cream 5 g intravaginally daily for 3 days
• Miconazole 2% cream 5 g intravaginally daily for 7 days
• Miconazole 4% cream 5 g intravaginally daily for 3 days
• Miconazole 200 mg vaginal suppository daily for 3 days 2, 1
• Terconazole 0.4% cream 5 g intravaginally daily for 7 days
• Terconazole 0.8% cream 5 g intravaginally daily for 3 days
• Terconazole 80 mg vaginal suppository daily for 3 days 2, 1

Treatment for Complicated Infection

Severe Vulvovaginal Candidiasis

When marked vulvar erythema, edema, excoriation, or fissure formation is present, do not use single-dose regimens; instead, prescribe extended therapy. 1

• Fluconazole 150 mg every 72 hours for a total of 2–3 doses 1, 3
• OR topical azole therapy for 7–14 days (using any of the regimens listed above) 2, 1

Non-albicans Species (e.g., Candida glabrata)

If vaginal culture identifies C. glabrata or if the patient fails standard azole therapy, switch to non-azole treatment because C. glabrata exhibits intrinsic azole resistance. 7

• Boric acid 600 mg intravaginal gelatin capsule daily for 14 days is the first-line treatment for C. glabrata, achieving clinical and mycological cure in 70–77% of patients. 7
• Nystatin 100,000 IU vaginal suppository daily for 14 days is an alternative. 7
• Avoid fluconazole monotherapy for confirmed C. glabrata, as response rates are below 50%. 7

Management of Recurrent Vulvovaginal Candidiasis (RVVC)

Recurrent vulvovaginal candidiasis is defined as ≥ 3 symptomatic episodes within a 12-month period and requires a two-phase treatment strategy. 1

Phase 1: Induction Therapy

Achieve clinical and mycological remission with 10–14 days of topical azole therapy OR oral fluconazole (e.g., fluconazole 150 mg every 72 hours for 3 doses). 1, 3

Phase 2: Maintenance Suppression

After confirming remission, initiate fluconazole 150 mg orally once weekly for 6 months. 1, 8

• This regimen controls symptoms in > 90% of patients during the 6-month treatment period. 1, 8
• The median time to recurrence is 10.2 months with maintenance therapy versus 4.0 months with placebo. 8
• After stopping maintenance therapy, anticipate a 40–50% recurrence rate. 1, 8

When to Suspect RVVC

Advise the patient to seek medical evaluation if she experiences ≥ 3 episodes within a 12-month period, as this meets criteria for RVVC and warrants long-term suppressive therapy. 1

Special Populations

Pregnancy

• Avoid oral fluconazole during pregnancy, especially in the first trimester, due to associations with spontaneous abortion and congenital malformations. 1, 3
• Use only topical azole therapy for 7 days in pregnant women. 1

HIV-Positive Women

• Treatment regimens and response rates are identical to those in HIV-negative women; do not alter therapy based on HIV status. 2, 1, 3

Immunocompromised Hosts

• Patients with uncontrolled diabetes or those receiving systemic corticosteroids may require extended therapy (7–14 days) rather than short-course regimens. 7

Critical Pitfalls to Avoid

• Do not treat empirically without microscopic confirmation, as fewer than 50% of women who self-diagnose yeast infection actually have candidiasis. 1
• Do not use short-course (1–3 day) regimens for severe vulvar inflammation; these cases require 7–14 days of therapy. 1
• Do not assume all vaginal symptoms are due to yeast; bacterial vaginosis and trichomoniasis require distinct treatments and present with overlapping symptoms. 1
• Do not treat asymptomatic colonization, as this is a normal finding in 10–20% of women. 1, 3
• Do not routinely treat sexual partners, as vulvovaginal candidiasis is not a sexually transmitted infection. 7
• Do not discontinue the 6-month maintenance regimen prematurely in patients with RVVC, as completing the full course maximizes the chance of prolonged remission. 1

Follow-Up Recommendations

• For uncomplicated infections with symptom resolution, routine follow-up is unnecessary. 3
• Instruct patients to return if symptoms persist after completing therapy or recur within 2 months, as this may indicate resistant organisms, non-albicans species, or an alternative diagnosis. 1, 3
• If ≥ 3 episodes occur within 12 months, obtain vaginal culture to identify the Candida species and initiate the two-phase RVVC protocol. 1

Adverse Effects and Drug Interactions

• Topical azoles rarely cause systemic side effects but may produce local burning or irritation. 1
• Oral fluconazole may cause nausea, abdominal pain, and headache; these effects are generally mild and transient. 1, 4
• Fluconazole interacts with multiple medications, including calcium channel blockers, warfarin, and protease inhibitors; review the patient's medication list before prescribing. 1
• Oil-based vaginal preparations may weaken latex condoms and diaphragms, risking contraceptive failure. 7