What are the recommended treatment options for uncomplicated vulvovaginal candidiasis in a non‑pregnant adult woman, and how do they differ in pregnancy or recurrent infection?

Treatment of Vaginal Yeast Infections

For uncomplicated vaginal yeast infections in non-pregnant women, either a single 150 mg oral dose of fluconazole or a short-course (1-7 days) topical azole achieves >90% cure rates and should be selected based on patient preference, cost, and contraindications. 1, 2, 3

Diagnostic Confirmation Before Treatment

Do not treat without laboratory confirmation, as self-diagnosis is accurate in fewer than 50% of cases. 1, 3

• Perform wet-mount microscopy with 10% potassium hydroxide to visualize budding yeast or pseudohyphae (positive in 50-70% of true cases). 1, 3
• Verify vaginal pH ≤4.5; a pH >4.5 suggests bacterial vaginosis or trichomoniasis instead. 1, 2, 4
• Obtain vaginal culture when microscopy is negative but clinical suspicion remains high, or in recurrent cases to identify non-albicans species. 1, 3

First-Line Treatment for Uncomplicated Infection

Oral Option (Most Convenient)

• Fluconazole 150 mg as a single oral dose provides 80-90% cure rates and is the most convenient regimen. 1, 2, 3, 5

Topical Options (Equally Effective)

Short-course regimens (3 days):

• Miconazole 200 mg vaginal suppository once daily for 3 days 1, 2, 3
• Terconazole 0.8% cream 5g intravaginally once daily for 3 days 1, 2, 3
• Terconazole 80 mg vaginal suppository once daily for 3 days 1, 2, 3
• Clotrimazole 100 mg vaginal tablet, two tablets for 3 days 3

Standard-course regimens (7 days):

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

Single-dose regimens:

• Clotrimazole 500 mg vaginal tablet as a single application achieves cure rates equivalent to multi-day regimens. 2, 3, 5

Critical Caveat

• Oil-based topical preparations (all creams and suppositories) may weaken latex condoms and diaphragms; advise alternative contraception during treatment. 2, 3

Treatment of Severe or Complicated Infection

Avoid single-dose regimens when marked vulvar erythema, edema, excoriation, or fissures are present. 1, 2

Extended Topical Therapy (7-14 days)

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

Alternative Oral Regimen

• Fluconazole 150 mg orally, repeated after 72 hours (two doses total) provides significantly higher cure rates than a single dose for severe disease. 1, 2

Treatment During Pregnancy

Oral fluconazole is contraindicated in pregnancy due to associations with spontaneous abortion and congenital malformations. 1, 2, 3

• Use only topical azole therapy for 7 days (not shorter courses). 1, 2, 3
• Acceptable agents include clotrimazole, miconazole, butoconazole, and terconazole. 2
• Seven-day regimens are more effective than shorter courses in pregnancy. 3

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

Recurrent infection requires a two-phase treatment strategy rather than repeated acute therapy. 1, 2, 3

Phase 1: Induction (Achieve Remission)

• 10-14 days of topical azole therapy (any regimen listed above) OR 1, 2, 3
• Fluconazole 150 mg orally, repeated after 72 hours (two doses total) 1, 2

Phase 2: Maintenance (Prevent Recurrence)

• Fluconazole 150 mg orally once weekly for 6 months controls symptoms in >90% of patients during treatment. 1, 2, 3, 6
• Alternative topical maintenance: clotrimazole 500 mg vaginal suppository weekly for 6 months. 2, 6
• After stopping maintenance therapy, expect a 40-50% recurrence rate. 1, 2, 7

Diagnostic Workup for Recurrent Cases

• Obtain vaginal culture to identify non-albicans species (especially C. glabrata), which account for 10-20% of recurrent cases and require different treatment. 1, 2, 7
• Consider antifungal susceptibility testing if symptoms persist despite appropriate therapy. 1

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

Standard azole regimens are substantially less effective against non-albicans species. 1, 8

First-Line for C. glabrata

• Boric acid 600 mg intravaginal gelatin capsule once daily for 14 days achieves approximately 70% cure rates. 1, 3, 6
• Boric acid is contraindicated in pregnancy. 1, 6

Alternative for C. glabrata

• Extended topical azole therapy (7-14 days) with terconazole, which has better activity against non-albicans species at vaginal pH. 1, 2
• Nystatin 100,000 units vaginal suppository daily for 14 days may be used but is less effective than azoles for C. albicans. 2, 3

Special Populations

Immunocompromised Patients (HIV, Uncontrolled Diabetes, Corticosteroid Use)

• Use the same regimens as immunocompetent women, but provide extended 7-14 day courses regardless of severity. 1, 2
• Optimize modifiable risk factors (glycemic control, minimize corticosteroids). 2

Fluconazole-Allergic Patients

• Use any topical azole regimen listed above; all achieve 80-90% cure rates without cross-reactivity concerns. 3

Critical Pitfalls to Avoid

• Do not treat asymptomatic Candida colonization (present in 10-20% of women); treatment is indicated only when symptoms are present with confirmed infection. 1, 2, 3
• Do not initiate therapy based solely on symptoms without microscopic or culture confirmation, as clinical features overlap significantly with bacterial vaginosis and trichomoniasis. 1, 3, 4
• Do not use short-course (1-3 day) regimens for severe vulvar inflammation; these require 7-14 day therapy. 1, 2
• Do not routinely treat sexual partners, as vulvovaginal candidiasis is not sexually transmitted and partner treatment does not reduce recurrence. 2, 3
• Exception: male partners with symptomatic balanitis may receive topical antifungal therapy for their own symptom relief. 2, 3
• Do not prescribe nystatin for C. albicans infections; topical azoles are more effective. 1, 3

Follow-Up Recommendations

• Patients should return for evaluation only if symptoms persist after completing therapy or recur within 2 months. 1, 2, 3
• If symptoms persist, obtain vaginal cultures to identify non-albicans species or azole resistance. 1, 2
• Women experiencing ≥4 episodes within a 12-month period meet criteria for recurrent infection and should be evaluated for maintenance therapy. 1, 2, 7

Over-the-Counter Self-Treatment

• Advise OTC azole therapy only for women previously diagnosed by a healthcare provider who experience recurrence of identical symptoms. 2, 3
• OTC preparations require 7-day treatment courses (e.g., clotrimazole 1% cream or miconazole 2% cream). 3
• Women whose symptoms persist after OTC treatment or who experience recurrence within 2 months must seek medical evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses. 1, 3