Oral Treatment for Vulvovaginal Candidiasis

First-Line Recommendation

A single oral dose of fluconazole 150 mg is the recommended first-line oral therapy for uncomplicated vulvovaginal candidiasis, achieving clinical cure rates exceeding 90%. 1, 2

This single-dose regimen provides efficacy equivalent to multi-day topical azole therapy while offering superior convenience and patient preference. 1, 3 The FDA-approved dosage for vaginal candidiasis is 150 mg as a single oral dose. 2

When to Use Single-Dose Oral Fluconazole

Use the standard 150 mg single dose when all of the following criteria are met:

Mild-to-moderate symptoms (pruritus, discharge, dysuria, dyspareunia) 1
Sporadic or infrequent episodes (<4 episodes per year) 1
Immunocompetent patient (no HIV, uncontrolled diabetes, or immunosuppression) 1
Likely Candida albicans etiology (no prior azole treatment failure) 1
Not pregnant (fluconazole is contraindicated in pregnancy) 4, 5

Diagnostic Confirmation Before Treatment

Never treat empirically without microscopic confirmation—self-diagnosis is accurate in only 30–50% of cases. 4

Before prescribing fluconazole, perform:

Wet-mount microscopy with 10% KOH to visualize yeast or pseudohyphae 1, 4
Vaginal pH measurement: pH ≤4.5 supports candidiasis; pH >4.5 suggests bacterial vaginosis or trichomoniasis 1, 4
Vaginal culture if wet mount is negative but symptoms persist 1, 4

Symptoms alone (pruritus, discharge, dysuria) are nonspecific and present in only ~50% of patients who self-diagnose yeast infection. 4

Modified Regimens for Complicated Disease

Severe Acute Vulvovaginal Candidiasis

When extensive vulvar erythema, edema, excoriation, or fissures are present:

Fluconazole 150 mg orally every 72 hours for 3 doses (total 450 mg over 6 days). 1, 4

Alternative: Topical azole therapy for 7–14 days. 1, 4

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

Two-phase approach: 1, 4

Induction phase: Fluconazole 150 mg every 72 hours for 3 doses (or topical azole for 10–14 days) 1, 4
Maintenance phase: Fluconazole 150 mg once weekly for 6 months 1, 4

Expected outcomes:

90% symptom control during maintenance therapy 1, 4
40–50% recurrence rate after discontinuation 1, 4
Median time to recurrence: 10.2 months with maintenance vs. 4.0 months without 4

Management of Treatment Failure

If symptoms persist beyond 5–7 days or recur within 2 months:

Obtain vaginal culture to identify non-albicans species (C. glabrata, C. krusei) 1, 4
Non-albicans species account for 10–20% of recurrent cases and are frequently azole-resistant 1, 4

Treatment for Candida glabrata Infection

First-line: Boric acid 600 mg intravaginal gelatin capsules daily for 14 days (compounded), achieving ~70% clinical and mycologic eradication 1, 4

Alternatives:

Nystatin 100,000 U intravaginal suppositories daily for 14 days 1, 4
Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days (specialist referral) 1, 4

Drug Interactions and Safety Considerations

Monitor closely for the following interactions: 1, 4

Warfarin: Potentiates anticoagulant effect, elevates INR, increases bleeding risk 1, 4
Oral hypoglycemics: Enhances hypoglycemic effect 4
Phenytoin: Increases toxicity risk 4
Calcineurin inhibitors (tacrolimus, cyclosporine): Increases drug levels 4
Protease inhibitors and calcium-channel blockers: Increases drug levels 4

Hepatic considerations:

Transient transaminase elevations are rare with single-dose therapy 1, 4
Baseline liver tests are not required in patients without known hepatic disease 1, 4

Critical Pitfalls to Avoid

Do not treat asymptomatic colonization: 10–20% of women harbor Candida without symptoms; treatment is not indicated 1, 4, 5
Do not use single-dose therapy for severe or recurrent disease: Extended regimens are required 1, 4
Do not treat sexual partners: Vulvovaginal candidiasis is not a sexually transmitted infection 4, 5
Do not prescribe nystatin for initial therapy: Topical azoles are more effective 5
Do not ignore treatment failure patterns: May indicate non-albicans species requiring alternative approaches 1, 4

Special Populations

Pregnancy

Oral fluconazole is contraindicated due to associations with spontaneous abortion and congenital malformations. 4, 5

Use only 7-day topical azole therapy. 4, 5

HIV-Positive Women

Treatment regimens and response rates are identical to HIV-negative women; no modification based solely on HIV status is required. 5

Pediatric Patients

The standard adult dose of 150 mg is appropriate for adolescents, as older children have clearances similar to adults. 1

What is the recommended oral therapy for uncomplicated vulvovaginal candidiasis?

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