What is the first‑line treatment for an uncomplicated vulvovaginal candidiasis in an adult woman?

First-Line Treatment for Uncomplicated Yeast Infection in Women

For an uncomplicated vaginal yeast infection, either a single 150 mg oral dose of fluconazole or a short-course topical azole (1–7 days) achieves cure rates exceeding 90% and should be offered as equally effective first-line options. 1

Diagnostic Confirmation Before Treatment

• Confirm the diagnosis with wet-mount microscopy using 10% potassium hydroxide to visualize budding yeast or pseudohyphae before starting therapy, because self-diagnosis is accurate in only 30–50% of cases. 1
• Measure vaginal pH with narrow-range pH paper: a pH ≤ 4.5 supports yeast infection, whereas pH > 4.5 suggests bacterial vaginosis or trichomoniasis. 1, 2
• Do not treat asymptomatic colonization, which occurs in 10–20% of healthy women and requires no therapy. 1, 2

First-Line Treatment Options

Oral Therapy (Most Convenient)

• Fluconazole 150 mg as a single oral dose is the most convenient regimen, achieving >90% cure rates in uncomplicated cases. 1, 3
• The FDA label confirms that fluconazole 150 mg achieves 55% therapeutic cure (complete symptom resolution plus negative culture) and 69% clinical cure in controlled trials. 3

Topical Azole Therapy (Equally Effective)

Short-course regimens (1–3 days):

• Clotrimazole 500 mg vaginal tablet as a single dose 1, 2, 4
• Miconazole 200 mg vaginal suppository daily for 3 days 1, 2
• Terconazole 0.8% cream 5 g intravaginally daily for 3 days 1, 2
• Terconazole 80 mg vaginal suppository daily for 3 days 1, 2

Standard-course regimens (7 days):

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

All topical azole regimens achieve 80–90% cure rates and are significantly more effective than nystatin. 1, 2

When to Modify the Standard Approach

Severe Vulvar Inflammation

• Avoid single-dose regimens when marked vulvar erythema, edema, excoriation, or fissures are present. Instead, prescribe a 7–14 day topical azole course or fluconazole 150 mg orally every 72 hours for 2–3 doses. 1

Pregnancy

• Use only a 7-day topical azole regimen in pregnant women; oral fluconazole is contraindicated due to associations with spontaneous abortion and congenital malformations. 1, 2, 5
• Recommended pregnancy regimens include clotrimazole 1% cream, miconazole 2% cream, or terconazole 0.4% cream, each 5 g intravaginally daily for 7 days. 1, 2

Recurrent Infections (≥4 Episodes per Year)

• Induction phase: 10–14 days of topical azole therapy or fluconazole 150 mg on days 1,4, and 7. 1, 5
• Maintenance phase: Fluconazole 150 mg orally once weekly for 6 months, which controls symptoms in >90% of patients during treatment. 1, 5, 6
• After stopping maintenance therapy, 40–50% of women will experience recurrence, so counsel patients accordingly. 1, 5

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

• Obtain vaginal cultures before starting maintenance therapy because 10–20% of recurrent cases are caused by C. glabrata, which is intrinsically resistant to fluconazole. 1, 5
• For confirmed C. glabrata: Boric acid 600 mg intravaginal capsules daily for 14 days achieves 70% eradication. 1, 5

Critical Pitfalls to Avoid

• Do not treat empirically without microscopic confirmation, as symptoms overlap significantly with bacterial vaginosis and trichomoniasis. 1
• Do not use single-dose regimens for severe vulvar inflammation; these cases require 7–14 day therapy. 1
• Do not routinely treat sexual partners, as vulvovaginal candidiasis is not a sexually transmitted infection. 1, 5
• Do not prescribe nystatin as first-line therapy; topical azoles are significantly more effective. 1, 2
• Do not start fluconazole maintenance without confirming species by culture, as you may be treating resistant C. glabrata. 5

Practical Considerations

• Oil-based topical creams and suppositories can weaken latex condoms and diaphragms; counsel patients to avoid concurrent use. 2
• Self-treatment with over-the-counter preparations should be limited to women with a prior clinician-confirmed diagnosis who experience identical recurrent symptoms. 1, 2
• Patients should seek medical evaluation if symptoms persist after treatment or recur within 2 months. 1, 2

Adverse Effects

• Topical azoles rarely cause systemic side effects but may produce local burning or irritation. 1
• Oral fluconazole may cause nausea (7%), abdominal pain (6%), headache (13%), and diarrhea (3%). 1, 3
• The FDA label reports that 31% of fluconazole-treated patients experienced any adverse event versus 27% with vaginal products, with gastrointestinal events being the primary difference (16% vs 4%). 3