Vulvovaginal candidiasis: Treatment of acute infection

VVC: vulvovaginal candidiasis; BV: bacterial vaginosis.

* Characteristics of severe infection include extensive vulvovaginal involvement, skin fissures, and/or edema.

¶ Candida albicans is the causative organismin 80 to 90% of vulvovaginal infections. The remainder are mostly C. glabrata or C. krusei.

Δ In our practice, patients generally prefer oral to vaginal medication and single-dose to multi-dose therapy. However, as no approach has demonstrated superiority, all treatments are reasonable options.

◊ The incidence of fluconazole allergy is uncommon. Individuals with fluconazole allergy, including angioedema and severe rash, can receive other topical azoles, such as miconazole or clotrimazole, ibrexafungerp, nystatin vaginal pessary, or vaginal boric acid.

§ There are multiple topical azoles including butoconazole, clotrimazole, miconazole, nystatin, terconazole, and tioconazole. Duration of treatment varies by drug and dose. Topical azole creams can also be applied externally for symptom reduction. Additional discussions on treatment of vulvovaginal candidiasis are available in related UpToDate content and Lexicomp drug monographs.

¥ Oral ibrexafungerp is a reasonable alternative for nonpregnant patients who prefer oral dosing but cannot use oral fluconazole. However, drug interactions and cost limit this approach. When used, ibrexafungerp is taken as two 150 mg tablets (ie, 300 mg) orally twice in one day (ie, two tablets in the morning and two at night).