What is the first‑line treatment for uncomplicated vulvovaginal candidiasis in a healthy adult non‑pregnant woman?

First-Line Treatment for Vaginal Yeast Infection

For uncomplicated vulvovaginal candidiasis in a healthy adult non-pregnant woman, either a single 150 mg oral dose of fluconazole or a short-course topical azole (1-7 days) is recommended as first-line therapy, with both achieving cure rates exceeding 90%. 1, 2

Diagnostic Confirmation Before Treatment

Before initiating therapy, confirm the diagnosis rather than treating empirically:

• Perform wet-mount microscopy with 10% potassium hydroxide to visualize budding yeast or pseudohyphae 3, 1
• Measure vaginal pH using narrow-range pH paper; vulvovaginal candidiasis presents with pH ≤ 4.5, whereas pH > 4.5 suggests bacterial vaginosis or trichomoniasis 3, 1, 4
• Obtain vaginal culture if microscopy is negative but clinical suspicion remains high, or for recurrent cases to identify non-albicans species 3, 1, 4

Critical pitfall: Self-diagnosis is accurate in only 30-50% of cases; symptoms of vulvovaginal candidiasis overlap significantly with bacterial vaginosis and trichomoniasis, which require entirely different treatments. 1, 4

First-Line Treatment Options for Uncomplicated Disease

Oral Therapy (Most Convenient)

Fluconazole 150 mg as a single oral dose is the most convenient first-line option, achieving >90% cure rates. 3, 1, 2, 5

Topical Azole Therapy (Equally Effective)

All of the following topical regimens achieve equivalent efficacy to oral fluconazole 3, 1:

Short-course options (3-day regimens):

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

Standard-course options (7-day regimens):

• Clotrimazole 1% cream 5 g intravaginally daily for 7 days 3, 1, 6
• Miconazole 2% cream 5 g intravaginally daily for 7 days 3, 1

Single-dose options:

• Clotrimazole 500 mg vaginal tablet as a single application 3, 6
• Tioconazole 6.5% ointment 5 g intravaginally as a single application 3, 1

When to Modify the Standard Approach

Severe Vulvar Inflammation

Do not use single-dose regimens when marked vulvar erythema, edema, excoriation, or fissure formation is present. 1, 7

Instead, prescribe:

• Topical azole therapy for 7-14 days using any of the standard-course regimens listed above 3, 1, 7, OR
• Fluconazole 150 mg orally every 72 hours for 2-3 total doses 3, 7

Recurrent Vulvovaginal Candidiasis (≥4 Episodes Per Year)

If the patient has experienced ≥4 symptomatic episodes within the past 12 months, a two-phase approach is mandatory 3, 1, 7:

Phase 1 (Induction): 10-14 days of topical azole therapy OR fluconazole 150 mg orally, repeated 72 hours later 3, 1, 7, 4

Phase 2 (Maintenance): Fluconazole 150 mg orally once weekly for 6 months 3, 1, 7, 8

• This maintenance regimen controls symptoms in >90% of patients during treatment 3, 1, 8
• Anticipated recurrence rate of 40-50% after stopping maintenance therapy 3, 1, 4, 8

Non-Albicans Species (Particularly C. glabrata)

If vaginal culture identifies C. glabrata (occurs in 10-20% of recurrent cases):

First-line: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days 3, 1, 7, 4

Second-line (if boric acid unavailable or not tolerated): Extended topical azole therapy for 7-14 days, though cure rates are substantially lower than for C. albicans 1, 4

Important: Standard single-dose fluconazole 150 mg is inadequate for C. glabrata infections. 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic colonization: 10-20% of women normally harbor Candida species without infection 3, 1, 7
• Do not use single-dose therapy for complicated disease: Reserve single-dose regimens only for uncomplicated mild-to-moderate cases 3, 1, 7
• Do not routinely treat sexual partners: Vulvovaginal candidiasis is not a sexually transmitted infection 3, 1
• Do not prescribe nystatin: Topically applied azole drugs are more effective than nystatin 3, 1

When to Seek Further Evaluation

Patients should return for medical evaluation if 1, 7, 4:

• Symptoms persist after completing appropriate therapy
• Symptoms recur within 2 months
• ≥4 episodes occur within a 12-month period (meeting criteria for recurrent vulvovaginal candidiasis)

Special Population: Pregnancy

In pregnant women, avoid oral fluconazole completely due to association with spontaneous abortion and congenital malformations. 1, 7, 4

Use only topical azole therapy for 7 days (not shorter courses). 1, 7, 4

Drug Interactions with Oral Fluconazole

Oral fluconazole may interact with quinidine, erythromycin, pimozide, calcium channel antagonists, warfarin, cyclosporine, protease inhibitors, oral hypoglycemic agents, and phenytoin. 7

Common adverse effects include nausea, abdominal pain, and headache. 7