Candidiasis – Vulvovaginal

Over-the-Counter Intravaginal Agents:

Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days 

OR  

Clotrimazole 2% cream 5 g intravaginally daily for 3 days  

OR  

Miconazole 2% cream 5 g intravaginally daily for 7 days  

OR  

Miconazole 4% cream 5 g intravaginally daily for 3 days  

OR  

Miconazole 100 mg vaginal suppository one suppository daily for 7 days  

OR  

Miconazole 200 mg vaginal suppository one suppository for 3 days  

OR  

Miconazole 1,200 mg vaginal suppository one suppository for 1 day  

OR  

Tioconazole 6.5% ointment 5 g intravaginally in a single application  

Prescription Intravaginal Agents:  

Butoconazole 2% cream (single-dose bioadhesive product) 5 g intravaginally in a single application  

OR  

Terconazole 0.4% cream 5 g intravaginally daily for 7 days  

OR  

Terconazole 0.8% cream 5 g intravaginally daily for 3 days  

OR  

Terconazole 80 mg vaginal suppository one suppository daily for 3 days  

Oral Agent: 

Fluconazole 150 mg orally in a single dose 

None

Vaginal culture or PCR should be obtained from women with complicated VVC to confirm clinical diagnosis and identify non–albicans Candida. 

Recurrent Vulvovaginal Candidiasis (VVC) 

Defined as 3 or more episodes of symptomatic VVC in <1 year 

Initial regimen* of: 

7–14 days of topical azole 

OR 

100-mg, 150-mg, or 200-mg oral dose of fluconazole every third day for a total of 3 doses (days 1, 4, 7)

*To maintain clinical and mycologic control, a longer duration of initial therapy is recommended, to attempt mycologic remission, before initiating a maintenance antifungal regimen. 

Followed by maintenance regimen: 

Fluconazole 100-mg, 150-mg, or 200-mg oral dose, weekly for 6 months 

Footnote: Intermittent topical azole use may be considered if weekly fluconazole is not feasible. Suppressive maintenance therapies are effective at controlling recurrent VVC but are rarely curative long-term. Because C. albicans azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist. 

Severe Vulvovaginal Candidiasis Severe 

7–14 days of topical azole  

or  

150 mg of fluconazole in two sequential oral doses (second dose 72 hours after initial dose) is recommended 

Non–albicans Vulvovaginal Candidiasis 

The optimal treatment of non–albicans VVC remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.  

If recurrence occurs, 600 mg of boric acid in a gelatin capsule administered vaginally once daily for 3 weeks is indicated.  

This regimen has clinical and mycologic eradication rates of approximately 70%. If symptoms recur, referral to a specialist is advised.

None

Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women.  

Fluconazole is no longer recommended in pregnancy. 

None

Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV.

None

Women with underlying immunodeficiency, those with poorly controlled diabetes or other immunocompromising conditions (e.g., HIV), and those receiving immunosuppression therapy (e.g., corticosteroid treatment) might not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7–14 days) conventional treatment is necessary. 

None