Treatment of uncomplicated vulvovaginal candidiasis

Drug and trade name(s)	Requires a prescription in US	Preparation	Intravaginal* dose for adult
Fluconazole oral administration^¶
Diflucan^Δ	Yes	150 mg oral tablet	Single dose by mouth; patients with greater vulvovaginal involvement may require an additional dose of 150 mg given 72 hours after initial dose
Clotrimazole
Gyne-Lotrimin^Δ	No	1% vaginal cream	1 applicatorful (approximately 5 g) once daily at bedtime for seven days
Gyne-Lotrimin 3^Δ	No	2% vaginal cream	1 applicatorful (approximately 5 g) once daily at bedtime for three days
Gyne-Lotrimin^◊	Not applicable (not available in US)	100 mg vaginal tablet^◊ 200 mg vaginal tablet^◊ 500 mg vaginal tablet^◊	Insert one 100 mg vaginal tablet once daily for seven days; or One 200 mg tablet once daily for three days; or One 500 mg tablet as a single dose
Miconazole
Monistat 7^Δ	No	2% vaginal cream (combination kit may include 2% miconazole cream for external use)	1 applicatorful (approximately 5 g) once daily at bedtime for seven days
Monistat 3^Δ	No	4% vaginal cream	1 applicatorful (approximately 5 g) once daily at bedtime for three days
Monistat 7^Δ	No	100 mg vaginal suppository	1 suppository once daily at bedtime for seven days
Monistat 3^Δ, Vagistat-3^Δ	No (combination kit) Yes (generic suppository)	200 mg vaginal suppository (combination kit may include 2% miconazole cream for external use)	1 suppository once daily at bedtime for three days
Monistat 1^Δ	No	1200 mg vaginal suppository (combination kit may include 2% miconazole cream for external use)	1 suppository for one day as a single dose
Nystatin^§
Nystatin vaginal^◊ (former US brand Mycostatin)	Commercial vaginal tablet not available in US; vaginal suppositories can be prepared by a licensed compounding pharmacy (prescription required)	100,000 unit vaginal tablet or suppository	Insert 1 vaginal tablet or suppository once daily for 7 days
Terconazole^¥
Generic only (former US brands Terazole 7, Zazole)^Δ	Yes	0.4% vaginal cream	1 applicatorful (approximately 5 g) once daily at bedtime for seven days
Generic only (former US brands Terazole 3, Zazole)^Δ	Yes	0.8% vaginal cream	1 applicatorful (approximately 5 g) once daily at bedtime for three days
Generic only (former US brands Terazole 3, Zazole)^Δ	Yes	80 mg vaginal suppository	1 suppository once daily at bedtime for three days
Tioconazole
Vagistat-1, Monistat 1-Day^Δ	No	6.5% vaginal ointment	1 applicatorful (approximately 5 g) at bedtime as a single dose
Butoconazole
Gynazole-1	Yes	2% vaginal cream	1 applicatorful (approximately 5 g) as a single dose
Ibrexafungerp
Brexafemme	Yes	150 mg oral tablet	Two 150 mg tablets (ie, 300 mg) by mouth twice a day for one day (4 tablets total). Limit use to non-pregnant patients who prefer oral dosing but cannot use oral fluconazole (eg, due to intolerance, allergy, or Candida infection resistant to fluconazole). Dose reduction required if taken with strong CYP3A inhibitors.
Boric acid
AZO Boric acid, others^‡	No	600 mg vaginal suppository	1 suppository once daily at bedtime for 7 days. Limit use to patients who are allergic to fluconazole and do not have access to other topical agents (ie, azoles and nystatin)^‡. Warning: boric acid may cause death if taken orally.

There are no significant differences in efficacy among topical and systemic azoles (cure rates >80% for uncomplicated vulvovaginal candidiasis [VVC]). Patients can generally expect improvement in 24 to 48 hours. Complete resolution may take one to two weeks. Criteria for determining whether infection is uncomplicated/sporadic and guidance on choice of therapy is provided in associated topic and separate algorithm for sporadic uncomplicated VVC.
Complicated or recurrent infections require different treatment choices and durations from those presented in this table; refer to separate topic and algorithm for recurrent or complicated VVC.

US: United States; VVC: vulvogaginal candidiasis.

* Except fluconazole and ibrexafungerp, which are given orally.

¶ Itraconazole is another oral antifungal that appears to be effective^[1].

Δ Generic equivalent preparation(s) are available in US.

◊ Not commercially available in US.

§ Cure rate with nystatin is 70 to 80%.

¥ Rare cases of anaphylaxis and toxic epidermal necrolysis have been reported during terconazole therapy.

‡ Boric acid efficacy established with compounded intravaginal capsules which are not commercially available.

Reference:

Pitsouni E, Iavazzo C, Falagas ME. Itraconazole vs fluconazole for the treatment of uncomplicated acute vaginal and vulvovaginal candidiasis in nonpregnant women: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2008; 198:153.

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Treatment of uncomplicated vulvovaginal candidiasis