Management of initial or infrequent episodes of vulvovaginitis caused by Candida and related species in adults

For assessment advice, see Assessment of vulvovaginitis caused by Candida and related species in adults.

For mild initial or infrequent episodes of vulvovaginitis caused by Candida and related species in adults, general measures such as wearing breathable underwear may be sufficient; see Treatment of noninfective prepubertal vulvovaginitis.

If Candida albicans is isolated or suspected, intravaginal therapy with an imidazole or nystatin is usually effective. Studies that compare regimens (eg duration, preparation, recurrence rate) are lacking. Occasionally, topical therapy irritates the vagina leading to worsening or persistent symptomsSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad, , 2020. Nystatin is less effective than an imidazole, but is generally better tolerated. Longer treatment courses are recommended in pregnancy; a systematic review found that a four-day course will cure just over 50% of patients, whereas a seven-day course cures over 90% of patientsSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020Young, 2001Ong, 2023.

For intravaginal therapy for nonsevere vulvovaginitis in adults when C. albicans is isolated or suspected, use:

1clotrimazole 1% vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 6 nights clotrimazole clotrimazole clotrimazole

OR

1clotrimazole 2% vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 3 nights clotrimazole clotrimazole clotrimazole

OR

1clotrimazole 10% vaginal cream 1 applicatorful intravaginally, at bedtime once only clotrimazole clotrimazole clotrimazole

OR

1clotrimazole 100 mg pessary intravaginally, once daily at bedtime for 6 nights clotrimazole clotrimazole clotrimazole

OR

1clotrimazole 500 mg pessary intravaginally, at bedtime once only clotrimazole clotrimazole clotrimazole

OR

2nystatin 100 000 units/5 g vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 14 nights. nystatin nystatin nystatin

Oral fluconazole is equally as effective as intravaginal imidazole therapy for acute C. albicans vulvovaginitisDenison, 2020. Avoid oral fluconazole in patients who are pregnant or who are trying to conceiveLiu, 2020Zhang, 2019. Single doses of oral fluconazole are safe in breastfeeding, but repeated or high doses should be avoidedSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad, , 2020.

If intravaginal therapy for C. albicans is not tolerated, or if the patient prefers oral therapy, use:

fluconazole 150 mg orally, as a single dose. For dosage adjustment in adults with kidney impairment, see fluconazole dosage adjustment. fluconazole fluconazole fluconazole

For severe vulvovaginitis in adults caused by C. albicans (eg extensive vulval erythema, oedema, excoriation and fissuring on external examination), useSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020Sobel, 1995Sobel, 2001:

1fluconazole 150 mg orally, on day 1 and day 4. For dosage adjustment in adults with kidney impairment, see fluconazole dosage adjustment fluconazole fluconazole fluconazole

OR

1clotrimazole 500 mg pessary intravaginally, at bedtime on day 1 and day 4. clotrimazole clotrimazole clotrimazole

If treatment with an imidazole or nystatin fails, the most likely reasons are misdiagnosis or inadequate treatment.

Nakaseomyces glabratus (formerly known as Candida glabrata) is isolated in 5% of patients. If N. glabratus is isolated, use:

1nystatin 100 000 units/5 g vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 14 nights nystatin nystatin nystatin

OR

2boric acid 600 mg (extemporaneously prepared in a gelatin capsule) intravaginally, once daily at bedtime for 14 days1Saxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020Sobel, 2003Ong, 2023. boric acid boric acid boric acid

Avoid using boric acid in pregnancy because it may be teratogenicAcs, 2006Ong, 2023Saxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020.

If Pichia kudriavzevii (formerly known as Candida krusei) is isolated or suspected, intravaginal therapy recommended above for N. glabratus (formerly known as Candida glabrata) may be appropriate, seek expert advice.

Low potency topical corticosteroids (eg hydrocortisone 1% cream) applied to the external area (not intravaginally) may accelerate symptomatic relief when used in conjunction with adequate antifungal therapySaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad Patient Representatives, , 2020Ong, 2023. Ointment formulations are preferred because cream formulations can be irritating.

1 For formulation details of boric acid vaginal capsules, see the Australian Pharmaceutical Formulary and Handbook (APF), which is available for purchase from the Pharmaceutical Society of Australia (PSA) website.Return