Vulvovaginal Candidiasis

Clinical Snapshot

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]

Recognize the Condition

Typical Presentation

The most inflammatory of the 3 discharge-causing infections.

Marked vulvovaginal pruritus — usually the dominant complaint.
Thick, white, clumpy, "curdy" discharge (classically described as resembling cottage cheese).
Vulvar and vaginal inflammation, sometimes with visible erythema, edema, or fissuring.
No characteristic odour.

Risk Factors

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.

Red Flags & Refer

Refer or investigate further for the following:

Recurrent VVC (4 or more episodes per year) — do not simply keep treating each episode the same way. Confirm the diagnosis by vaginal culture with species identification before committing to a prolonged maintenance regimen, since non-albicans species and other diagnoses both change management.

Assessment & Diagnosis

Differentiating the 3 vaginal discharge infections

Parameter	Vulvovaginal candidiasis	Trichomoniasis	Bacterial vaginosis
Pruritus	Present	Present	Absent
Odour	Absent	Present	Present (fishy)
Discharge	White, clumpy and curdy	Off-white or yellow, frothy	Grey or milky, thin, copious
Inflammation	Present	Present	Absent
Vaginal pH	Under 4.5 (normal)	Over 4.5	Over 4.5
"Whiff" test (KOH)	Negative	Negative	Positive
Microscopy, specific finding	Budding yeast, pseudohyphae	Motile trichomonads	Clue cells; predominant gram-negative curved bacilli and coccobacilli
Microscopy, PMNs	Increased	Markedly increased	Not increased
Microscopy, lactobacilli	Present	Absent	Absent

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]

Treatment Targets

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.

Choose Initial Treatment

Direct treatment rule

Treat symptomatic, uncomplicated VVC with either an intravaginal azole antifungal or a single oral dose of fluconazole 150 mg — both are effective first-line options.

Use oral fluconazole when the patient prefers a single oral dose over intravaginal application and there is no contraindication (see Special Populations for pregnancy); use an intravaginal azole when oral therapy is undesired, not tolerated, or contraindicated.

Do not treat asymptomatic candidiasis found incidentally.^[1]

No longer recommended

Topical nystatin is less effective than the azole antifungals and should not be used.

Non-Pharmacologic Treatment

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.

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
Fluconazole Preferred	Uncomplicated VVC, single oral dose	150 mg PO as a single dose	Headache, nausea, abdominal pain, diarrhea, dyspepsia	Use when the patient prefers a single oral dose over intravaginal application and there is no contraindication.
Clotrimazole Preferred	Uncomplicated VVC, intravaginal	200 mg vaginal tablet PV daily for 3 days, or 500 mg vaginal tablet PV as a single dose	Local hypersensitivity	Safe in pregnancy. Menstruation is not a reason to stop treatment.
Miconazole Preferred	Uncomplicated VVC, intravaginal	400 mg ovule PV daily for 3 days, or 1200 mg ovule PV as a single dose	Local hypersensitivity	Ovules contain mineral oil, which may reduce condom/diaphragm effectiveness. Use a 7-14 day course in pregnancy.
Fluconazole (recurrent VVC induction) Special situation	Recurrent VVC (4+/year), induction	150 mg PO every 72 hours for 3 doses	Same as above	Confirm diagnosis and species by vaginal culture first.
Fluconazole (recurrent VVC maintenance) Special situation	Recurrent VVC, maintenance	150 mg PO weekly for a minimum of 6 months	Same as above	Address predisposing factors (uncontrolled diabetes, HIV) at the same time.
Boric acid vaginal capsules Special situation	Recurrent non-albicans VVC only	300-600 mg PV daily for 14 days, then 300 mg PV for 5 days per month for at least 6 months	Local irritation, vaginal burning	Toxic and potentially fatal if taken orally — counsel clearly. Contraindicated in pregnancy.

No longer recommended: topical nystatin is less effective than the azole antifungals.^[1]

Special Populations

Pregnancy: routine screening for VVC in pregnancy is not necessary — the risks are limited to bothersome symptoms, and recurrences are common in pregnancy regardless of treatment. If symptomatic, treat with a topical azole antifungal. Avoid oral fluconazole in pregnancy where possible: doses above 150 mg in the first trimester are potentially teratogenic, and even the single 150 mg dose has an uncertain association with miscarriage that has not been established as causal. A single 150 mg oral dose remains an available second-line option specifically if topical therapy fails or cannot be used.^[2]

Boric acid vaginal capsules are contraindicated in pregnancy.

Monitoring & Follow-Up

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.

Treatment Failure / Next Step

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

Common Errors to Avoid

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).

Clinical Decision Algorithm

Vulvovaginal candidiasis: isolated episode versus recurrent disease

Vulvovaginal pruritus with thick white curdy discharge and inflammation

Symptomatic

How many episodes in the past year?

Under 4 episodes/year

Intravaginal azole course, or oral fluconazole 150 mg single dose

4 or more episodes/year

Confirm diagnosis and species by vaginal culture

Induction: topical azole 10-14 days, or oral fluconazole

Maintenance: oral fluconazole 150 mg weekly x 6 months, or oral itraconazole monthly x 6 months; address predisposing factors

Asymptomatic

No treatment indicated, even if Candida is identified incidentally on testing

Drug Tables

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.

Drug	Dosage	Adverse effects	Comments
Fluconazole, uncomplicated infection Diflucan One, generics	150 mg PO as a single dose.	Headache, nausea, abdominal pain, diarrhea, dyspepsia, dizziness.	Avoid in pregnancy where possible; a single 150 mg dose is an available second-line option if topical therapy fails or cannot be used.
Fluconazole, recurrent infection (4+/year) Diflucan One, generics	150 mg PO every 72 hours x 3 doses (induction), then 150 mg PO weekly for a minimum of 6 months (maintenance).	Same as above.	Confirm the diagnosis and species by vaginal culture first. Consider referral for recurrent disease.
Itraconazole, recurrent infection maintenance Sporanox, generics	200-400 mg PO monthly x 6 months, following a topical azole induction course of 10-14 days.	Nausea, diarrhea; generally well tolerated given infrequent dosing.	Other antifungals (oral fluconazole, topical azoles) are generally preferred for maintenance; reserve for patients who need this specific option.

Azole Antifungals, Topical

First-line for uncomplicated infection; safe in pregnancy.

Drug	Dosage	Adverse effects	Comments
Clotrimazole Canesten Vaginal, generics	200 mg vaginal tablet once daily PV x 3 days, or 500 mg vaginal tablet PV as a single dose, or 1% cream once daily PV x 6 days, or 2% cream once daily PV x 3 days, or 10% cream PV as a single dose.	Local hypersensitivity.	Menstruation is not a reason to stop treatment. Safe in pregnancy, though a 7-14 day course may be needed.
Miconazole Monistat, generics	400 mg ovule once daily PV x 3 days, or 1200 mg ovule PV as a single dose, or 2% cream once daily PV x 7 days, or 4% cream once daily PV x 3 days.	Local hypersensitivity.	Ovules contain mineral oil, which may reduce the effectiveness of latex condoms and diaphragms. Use a 7-14 day course in pregnancy.
Terconazole 0.4% cream generics	1 applicatorful (5 g) PV at bedtime x 7 days.	Local hypersensitivity; very rare anaphylaxis or toxic epidermal necrolysis.	Advise the patient to stop treatment and seek care if signs of an allergic reaction appear.

Weak Acids

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

Drug	Dosage	Adverse effects	Comments
Boric acid vaginal capsules compounded	300-600 mg gelatin capsule PV once daily x 14 days, then maintain with 300 mg PV x 5 days per month starting on day 1 of the menstrual cycle, continued for at least 6 months.	Local irritation, vaginal burning, more pronounced with higher doses.	Consider only for confirmed non-albicans VVC. Toxic, potentially fatal, if taken orally — counsel clearly. Contraindicated in pregnancy. May irritate a sexual partner exposed to it.

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]

References

Sexually transmitted and blood-borne infections: Guides for health professionals — Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections
Use of oral fluconazole during pregnancy and the risk of birth defects — New England Journal of Medicine (Mølgaard-Nielsen D, Pasternak B, Hviid A). N Engl J Med 2013;369(9):830-839

Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.