Vulvovaginal Candidiasis

Vulvovaginal candidiasis (VVC) is most often caused by Candida albicans. It is generally not considered a sexually transmitted infection, and male sexual partners are not treated in most cases — partner treatment is only considered in patients with recurrent infection. VVC ranges from an isolated, easily treated episode to recurrent disease (4 or more episodes per year) that requires investigation, extended induction-and-maintenance therapy, and sometimes referral.^[1]

• Recent systemic antibiotic use, which disrupts protective vaginal flora.
• Poorly controlled diabetes mellitus.
• Pregnancy.
• Immunosuppression, including HIV infection.
• Estrogen exposure (combined oral contraceptives, hormone therapy) is a proposed contributor.
• For recurrent disease specifically: any of the above, or no identifiable predisposing factor at all in many patients.

Differentiating the 3 vaginal discharge infections

Nonsexually transmitted causes of vaginitis are also common and include atrophic vaginitis, trauma, contact or irritant dermatitis (detergents, contraceptive chemicals), foreign bodies, and allergy (e.g., latex condoms). Candidiasis and bacterial vaginosis are not generally considered sexually transmitted; trichomoniasis is.

Diagnosis is usually clinical, supported by microscopy showing budding yeast and pseudohyphae, a normal vaginal pH (under 4.5), and a negative whiff test — these findings distinguish VVC from bacterial vaginosis and trichomoniasis (see the comparison table above). For recurrent VVC specifically, confirm the diagnosis with vaginal culture and species identification rather than treating empirically again — this identifies non-albicans species, which may need a different treatment approach.^[1]

• Resolve pruritus, discharge, and inflammation in symptomatic patients.
• For recurrent disease: achieve durable remission through induction plus an extended maintenance course, and identify any correctable predisposing factor.

• No partner treatment is needed for an isolated episode; consider treating a partner only in the context of recurrent infection.
• Address a clearly identified predisposing factor when one exists — for example, glycemic control in diabetes.
• Avoid unnecessary antibiotic use, and consider prophylactic antifungal therapy at the start of an antibiotic course in a patient who is prone to antibiotic-associated VVC.

Boric acid vaginal capsules are contraindicated in pregnancy.

• Follow up if symptoms persist despite treatment, or recur within 2 months of the initial episode — both warrant reassessment rather than simply repeating the same treatment.
• For recurrent VVC on maintenance therapy, reassess periodically during the 6-month course and again after maintenance therapy is stopped, since recurrence after stopping extended therapy is common.

1. Reconsider the diagnosis — rule out bacterial vaginosis, trichomoniasis, contact dermatitis, or another cause of vulvovaginal symptoms using the comparison table above.
2. If VVC is confirmed and this is a repeat episode, obtain a vaginal culture with species identification rather than continuing to treat empirically.
3. Move to the recurrent-VVC induction-and-maintenance strategy once 4 or more episodes in a year are confirmed.
4. Look specifically for a non-albicans species or an unaddressed predisposing factor (uncontrolled diabetes, HIV) when maintenance therapy is not controlling symptoms.
5. Refer for gynecologic assessment if recurrence continues despite an adequate maintenance regimen.

• Using topical nystatin — it is less effective than the azole antifungals and is no longer recommended.
• Treating recurrent VVC with repeated short courses instead of moving to an induction-and-maintenance strategy once 4 or more episodes per year are confirmed.
• Using oral fluconazole above 150 mg, or using it at all when avoidable, in the first trimester of pregnancy.
• Treating a partner for an isolated, uncomplicated episode — this is not indicated.
• Missing bacterial vaginosis or trichomoniasis in a patient assumed to have VVC because of discharge alone, without checking for the distinguishing features (pruritus, odour, pH, whiff test).

How to use this table: Doses are adult doses and require patient-specific confirmation, including renal/hepatic adjustment. Select any drug name to open its complete Pharmasist Drug Database page.

Azole Antifungals, Oral

First-line systemic option for uncomplicated infection; also used for recurrent-disease maintenance.

Azole Antifungals, Topical

First-line for uncomplicated infection; safe in pregnancy.

Weak Acids

Reserved for recurrent non-albicans VVC where azole evidence is weaker.

Not effective: topical nystatin is less effective than the azole antifungals and is no longer a recommended treatment.

Evidence note: Drug inventory, dosing, adverse effects, and comments reflect standard Canadian practice per current PHAC guidance.^[1]