Definitions of uncomplicated and complicated Candidiasis1
| Uncomplicated candidiasis | Complicated candidiasis |
|---|---|
| Sporadic or infrequent episodes | Recurrent episodes (four or more per year) |
| Mild to moderate symptoms | Severe symptoms |
| Candida albicans infection | Non-albicans Candidal infection |
| Non-pregnant women without medical complications | Women with diabetes, severe medical illness, immunosuppression, pregnancy, other vulvovaginal conditions |
| Treatment action | Topical/behavioral | Vaginal meds | Oral meds | Testing and notes |
|---|---|---|---|---|
| Comfort measures and general treatment for uncomplicated candidiasis | Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs | CLOTRIMAZOLE (non-prescription):Gyne-Lotrimin 1% cream; 1 applicatorful vaginally at bedtime x 7 daysGyne-Lotrimin-3 2% cream; 1 applicatorful vaginally at bedtime x 3 days
Gyne-Lotrimin 100 mg vaginal tablet (not available in the USA); 1 tab vaginally at bedtime x 7 days or 2 tabs x 3 days MICONAZOLE (non-prescription) Monistat-7 2% cream; 1 applicatorful vaginally at bedtime x 7 days Monistat-3 4% cream; 1 applicatorful vaginally at bedtime x 3 days Monistat-7 100 mg vaginal suppository; 1 vaginally at bedtime x 7 days Monistat-3/Vagistat-3 (generic) 200 mg vaginal suppository; 1 vaginally at bedtime x 3 days Monistat-1, 1,200 mg vaginal suppository, 1 vaginally at bedtime x 1 NYSTATIN (not available in the US) 100,000 unit vaginal tablet; 1 tablet vaginally x 1 TERCONAZOLE (prescription only) Terazol or Zazole-7 0.4%; 1 applicatorful vaginally at bedtime x 7 days Terazol or Zazole-3 0.8%; 1 applicatorful vaginally at bedtime x 3 days Terazol or Zazole-3 80 mg vaginal suppository; 1 vaginally at bedtime x 3 days TIOCONAZOLE (non prescription) Vagistat-1 or 1-day from Monistat 6.5% ointment; 1 applicatorful vaginally x 1 BUTOCONAZOLE (prescription only) |
Fluconazole 150 mg oral tablet, one tablet in single dose | pH and microscopy are first line tests. Unless pseudohyphae are seen clearly on microscopy, send a yeast culture. Budding spores are associated with either albicans or non-albicans Candida. Cultures help with speciation and direct treatment. For uncomplicated yeast, any topical azole can be used. Any topical azole can cause increased symptoms of vulvar burning or irritation. Make patients aware of this potential side effect. Fluconazole has potential drug-to-drug adverse interactions. It is thought that the low doses we use for treatment or suppression of vulvovaginal yeast are unlikely to cause these interactions2 but awareness of the possibility is important. In addition, in a nationwide cohort study in Denmark, use of oral fluconazole in pregnancy was associated with a statistically significant increased risk of spontaneous abortion compared with risk among unexposed women and women with topical azole exposure in pregnancy. Until more data on the association are available, Fluconazole should not be prescribed in pregnancy, especially prior to 25 weeks. Although the risk of stillbirth was not significantly increased, this outcome should be investigated further. 3 For more information on candidiasis, see LINK Annotation P: candidiasis and The Atlas, candidiasis) |
| Comfort measures and general treatment for complicated candidiasis, severe symptoms | Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs | Any intravaginal azole used for 7-14 days | Fluconazole 150 mg orally x 1 and again in 72 hours; in severe cases, may be used a third time. | |
| Treatment of recurrent albicans candidiasis | Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs | Any intravaginal azole used for 7-14 days followed by the same azole used once or twice weekly for four to six months (frequency dependent on strength of medication) | Fluconazole 150 mg orally every 72 hours x 3 followed by 150 mg orally once a week for four-six months | |
| Treatment of non-albicans yeast in symptomatic non-pregnant women (therapy depends on strain of yeast identified) | Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs | For C. glabrata: Compounded boric acid capsules or suppositories, 600 mg intravaginally, nightly x 14 daysANDIf not effective, prescribe a second treatment with boric acid capsules or suppositories intravaginally: 600 mg suppository nightly x 14 days followed by compounded flucytosine cream 17%, 5 grams intravaginally for 14 daysORAmphotericin B compounded suppositories, 50 mg intravaginally nightly for 14 daysFor C. Krusei: Intravaginal Clotrimazole, Miconazole, or Terconazole for 7-14 days |
For species other than glabrata or krusei: Fluconazole 150 mg orally x 1 and again in 72 hours |
Asymptomatic non-albicans yeast does not always need treatment. Rule out other causes for symptoms before deciding on treatment. |
| Treatment of candidiasis in pregnancy | CLOTRIMAZOLE Gyne-Lotrimin 1% cream; 1 applicatorful vaginally at bedtime x 7 daysORMICONAZOLE Monistat-7 2% cream; 1 applicatorful vaginally at bedtime x 7 days |
Symptomatic, recurrent candidiasis can be problematic in pregnancy; the vaginal azole may need to be repeated or used for a longer course. There is no association with adverse outcomes from vaginal candidiasis in pregnancy.4Terazol should not be used in pregnancy. There is a warning attached to Terazol that there have been cases of anaphylaxis with it. Oral fluconazole should not be used in pregnancy.5 ( |
||
| Treatment of candidiasis in the immunocompromised woman | Any azole vaginally for 7-14 days: | Fluconazole 150 mg orally x 1 and again in 72 hours; in severe cases, may be used a third time. |
Updated 7/14/14. Candidiasis in annotations and in Atlas.
References
- Sobel JD. Candida vulvovaginitis. UpToDate. 2014, Wellesley, Massachusetts.
- Sobel JD. Candida vulvovaginitis. UpToDate. 2014, Wellesley, Massachusetts.
- Ditte Mølgaard-Nielsen, MSc; Henrik Svanström, PhD; Mads Melbye, MD, DrMedSci; Anders Hviid, MSc, DrMedSci; Björn Pasternak, MD, PhD. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67. doi:10.1001/jama.2015.17844
- Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR Recomm Rep 2010 (RR-11); 55:1-95.
- Ditte Mølgaard-Nielsen, MSc; Henrik Svanström, PhD; Mads Melbye, MD, DrMedSci; Anders Hviid, MSc, DrMedSci; Björn Pasternak, MD, PhD. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67. doi:10.1001/jama.2015.17844