What is the first‑line treatment for vulvovaginal candidiasis in an otherwise healthy adult woman, and what are the recommended alternatives for pregnant patients, treatment failure, and recurrent infection?

Vulvovaginal Candidiasis: First-Line Treatment and Management

For uncomplicated vulvovaginal candidiasis in healthy adult women, either a single 150 mg oral dose of fluconazole OR a short-course (1-7 day) topical azole regimen achieves >90% cure rates and represents equally effective first-line therapy. 1, 2

Diagnostic Confirmation Before Treatment

• Confirm diagnosis with wet-mount microscopy using 10% KOH to visualize budding yeast or pseudohyphae, rather than treating based on symptoms alone, because self-diagnosis is accurate in only 30-50% of cases. 1, 2
• Verify vaginal pH ≤4.5 to distinguish candidiasis from bacterial vaginosis (pH >4.5) or trichomoniasis. 1, 2
• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida species without infection. 1, 2

First-Line Treatment Options for Uncomplicated VVC

Oral Therapy (Most Convenient)

• Fluconazole 150 mg as a single oral dose 1, 2

Over-the-Counter Topical Azoles

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1, 2
• Clotrimazole 2% cream 5g intravaginally daily for 3 days 1
• Miconazole 2% cream 5g intravaginally daily for 7 days 1, 2
• Miconazole 200 mg vaginal suppository daily for 3 days 1, 2
• Tioconazole 6.5% ointment 5g intravaginally as single application 1, 2

Prescription Topical Azoles

• Terconazole 0.4% cream 5g intravaginally daily for 7 days 1, 2
• Terconazole 0.8% cream 5g intravaginally daily for 3 days 1, 2
• Butoconazole 2% cream 5g intravaginally as single application 1, 2

All topical azole regimens achieve 80-90% symptom relief and negative cultures after therapy completion. 1, 2

Treatment for Pregnant Patients

Pregnant women must receive ONLY topical azole therapy for 7 days; oral fluconazole is strictly contraindicated at any dose throughout pregnancy due to associations with spontaneous abortion and congenital malformations. 2, 3

Recommended Regimens in Pregnancy

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 3
• Miconazole 2% cream 5g intravaginally daily for 7 days 3
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 3

Seven-day courses are significantly more effective than shorter regimens during pregnancy, achieving 80-90% cure rates. 3

Critical Safety Points for Pregnancy

• High-dose fluconazole (≥400 mg daily) causes a distinct pattern of congenital anomalies including craniosynostosis, facial dysmorphisms, and limb contractures. 3
• Boric acid suppositories are absolutely contraindicated during pregnancy. 3
• For severe vulvovaginitis in pregnancy, extend topical azole therapy to 7-14 days rather than using systemic agents. 3

Management of Treatment Failure

When Initial Therapy Fails

• Suspect non-albicans Candida species (especially C. glabrata) if symptoms persist after appropriate azole therapy. 2
• Obtain vaginal culture to identify the species and guide therapy selection. 1, 2
• For confirmed C. glabrata infection, prescribe boric acid 600 mg intravaginally daily for 14 days as first-line therapy, because this species shows reduced azole susceptibility. 2

Severe Vulvovaginal Candidiasis

• When marked vulvar erythema, edema, excoriation, or fissures are present, avoid single-dose regimens and instead prescribe extended topical azole therapy for 7-14 days. 1, 2

Recurrent Vulvovaginal Candidiasis (RVVC)

RVVC is defined as ≥3 symptomatic episodes within 12 months and requires a two-phase treatment approach. 2

Two-Phase Treatment Protocol

Phase 1: Induction (Achieve Remission)

• 10-14 days of topical azole therapy OR oral fluconazole 150 mg every 72 hours for 2-3 doses 1, 2

Phase 2: Maintenance (Prevent Recurrence)

• Fluconazole 150 mg orally once weekly for 6 months 1, 2
• This regimen controls symptoms in >90% of patients during treatment 2
• However, 40-50% of women experience recurrence after stopping the 6-month maintenance course 1, 2, 4

Special Considerations for RVVC

• Obtain vaginal culture before initiating maintenance therapy to identify non-albicans species that may require alternative management. 2
• Consider antifungal susceptibility testing if repeated treatment failures occur, particularly with C. glabrata infections. 2
• RVVC significantly impacts quality of life, causing reduced self-esteem, sexual satisfaction, and work productivity beyond physical symptoms. 2, 5

Common Pitfalls to Avoid

• Do not treat empirically without microscopic confirmation, as symptoms overlap significantly with bacterial vaginosis and trichomoniasis. 1, 2
• Do not use short-course (1-3 day) regimens for severe vulvar inflammation; these cases require 7-14 day therapy. 1, 2
• Do not routinely treat sexual partners, as VVC is not a sexually transmitted infection; treat partners only if they have symptomatic balanitis. 3
• Do not assume all vaginal symptoms are yeast infection; self-diagnosis is unreliable and leads to inappropriate treatment. 1, 2
• Any woman whose symptoms persist after OTC treatment or who experiences recurrence within 2 months must seek medical evaluation to rule out resistant organisms or alternative diagnoses. 1, 2

HIV-Positive Patients

Treatment regimens and expected clinical response are identical for HIV-positive and HIV-negative women; therapy does not need modification based on HIV status alone. 1, 2