Vulvovaginal Candidiasis (VVC)
The CDC guidelines recommend oral fluconazole (i.e., 100-, 150-, or 200-mg dose) weekly for 6 months as the first-line maintenance regimen in RVVC. The CDC also states that if this oral regimen is not feasible, topical treatments used intermittently can also be considered. 3 However, the CDC does not provide recommendations for the type or frequency of topical maintenance, leaving clinicians without templates regarding best practice.
Topical Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus
1 Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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Gloria Bachmann
1 Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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Hope Haefner
2 Department Obstetrics and Gynecology, University of Michigan University Hospital, Ann Arbor, Michigan, USA.
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Mark Martens
3 Department Obstetrics and Gynecology, Tower Health, West Reading, Pennsylvania, USA.
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Colleen Stockdale
4 Department Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa, USA.
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1 Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
2 Department Obstetrics and Gynecology, University of Michigan University Hospital, Ann Arbor, Michigan, USA.
3 Department Obstetrics and Gynecology, Tower Health, West Reading, Pennsylvania, USA.
4 Department Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa, USA.
*Address correspondence to: Nancy Phillips, MD, Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, New Brunswick, NJ 08901, USA, [email protected]
Accepted 2021 Dec 7; Collection date 2022.
© Nancy A. Phillips et al., 2022; Published by Mary Ann Liebert, Inc.
This Open Access article is distributed under the terms of the Creative Commons License [CC-BY] (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
PMCID: PMC8812501 PMID: 35136875
Abstract
Background: Recurrent vulvovaginal candidiasis (RVVC), defined as three or more confirmed infections over 1 year, occurs in up to 10% of women. In these women, the objective is often symptomatic control rather than mycologic cure. Current Centers for Disease Control and Prevention (CDC) guidelines recommend oral fluconazole as first-line maintenance, but state if this oral regimen is not feasible, intermittent topical treatments can be considered. No specific recommendations for type or frequency of topical applications are provided by the CDC.
Methods: A panel of vulvovaginal experts convened to develop a consensus recommendation for topical maintenance dosing for RVVC.
Results: Data suggest that clotrimazole, miconazole, terconazole, and intravaginal boric acid are suggested recommendations for recurrent vulvovaginitis caused by both Candida albicans and nonalbicans species. Nystatin ovules may not be as effective as azoles. Identification of species will influence treatment decisions. In addition, treatment may be modified based on prior response to a specific agent, especially in nonalbicans species. Fluconazole, ibrexafungerp, and intravaginal boric acid should be avoided during pregnancy.
Conclusions: The expert consensus for women with RVVC is an initial full course of treatment followed by topical maintenance beginning at one to three times weekly, based on chosen agent. Twice a week dosing was the regimen most often utilized. In some women, episodic treatment may be used, but maintenance should remain an option for this population.
Keywords: consensus review, recurrent yeast, vulvovaginitis, candidiasis, topical therapy
Introduction
Vulvovaginal candidiasis (VVC) occurs when a Candida species causes a local inflammatory response, resulting in itching, irritation, burning, and/or dyspareunia. Up to 49% of women over the age of 16 years and 55% of college-aged women report having had at least one previously clinically diagnosed episode of VVC. 1 Data suggest that recurrent vulvovaginal candidiasis (RVVC) (previously defined as four or more infections in
The Centers for Disease Control and Prevention (CDC) guidelines for treatment of uncomplicated VVC (Table 1) include short-course topical formulations, available over the counter (OTC) or by prescription or a single dose of oral fluconazole. These therapies result in relief of symptoms and negative cultures in 80%–90% of women who complete therapy. 3
Table 1.
2015 Centers for Disease Control and Prevention Recommendations a for Acute Treatment of Uncomplicated b Vulvovaginal Candidiasis
| Over-the-counter intravaginal agents | |
| Clotrimazole 1% cream | 5 g intravaginally daily for 7–14 days |
| Clotrimazole 2% cream | 5 g intravaginally daily for 3 days |
| Miconazole 2% cream | 5 g intravaginally daily for 7 days |
| Miconazole 4% cream | 5 g intravaginally daily for 3 days |
| Miconazole 100 mg vaginal suppository | One suppository daily for 7 days |
| Miconazole 200 mg vaginal suppository | One suppository for 3 days |
| Miconazole 1,200 mg vaginal suppository | One suppository for 1 day |
| Tioconazole 6.5% ointment 5 g intravaginally | In a single application |
| Prescription intravaginal agents | |
| Butoconazole 2% cream bioadhesive product | 5 g single intravaginal application |
| Terconazole 0.4% cream | 5 g intravaginally daily for 7 days |
| Terconazole 0.8% cream | 5 g intravaginally daily for 3 days |
| Terconazole 80 mg vaginal suppository | One suppository daily for 3 days |
| Oral agent | |
| Fluconazole c 150 mg orally in a single dose | |
Adapted from CDC Sexually Transmitted Infections Treatment Guidelines, 2021 (https://www.cdc.gov/std/treatment-guidelines/candidiasis).
New CDC guidelines being released in late 2021.
Uncomplicated: sporadic or infrequent VVC and mild-to-moderate VVC and likely to be Candida albicans and nonimmunocompromised women.
Fluconazole should be avoided during pregnancy.
CDC, Centers for Disease Control and Prevention; VVC, vulvovaginal candidiasis.
In women with RVVC, mycologic cure is more difficult to achieve. To maintain clinical and mycologic control, a longer duration of initial therapy (e.g., 7–14 days of topical therapy or a 100-, 150-, or 200-mg oral dose of fluconazole every third day for a total of three doses [days 1, 4, and 7]) is recommended, to attempt mycologic remission, before initiating a maintenance antifungal regimen. (Maintenance therapy for control of clinical symptoms rather than treatment of each episode of VVC is recommended.) Confirmation of RVVC and identification of species are important to guide therapy.
The CDC guidelines recommend oral fluconazole (i.e., 100-, 150-, or 200-mg dose) weekly for 6 months as the first-line maintenance regimen in RVVC. The CDC also states that if this oral regimen is not feasible, topical treatments used intermittently can also be considered. 3 However, the CDC does not provide recommendations for the type or frequency of topical maintenance, leaving clinicians without templates regarding best practice.
Nor does the CDC define when oral fluconazole is not feasible. Women generally prefer an oral over topical regimen based on convenience, and fluconazole should remain the treatment of choice in appropriate candidates. However, the need for topical maintenance therapies is based on several limitations of oral fluconazole suppression. Fluconazole use should be avoided or closely monitored in women on statin drugs, and those with kidney disease or at high risk for arrhythmias. Other potential drug interactions should also be checked before prescribing fluconazole. 4
In addition, according to a 2015 nationwide cohort study from Denmark, women who had taken fluconazole during pregnancy were at a significantly increased risk of miscarriage compared with those with no exposure to fluconazole and with women who had used a topical azole drug. 5 This should be considered with the use of fluconazole in women of childbearing age. Importantly, fluconazole may not be effective against nonalbicans species, which are estimated to be responsible for up to 20% of RVVC. Candida glabrata is thought to be responsible for most nonalbicans species, with less virulent species such as Candida parapsilosis and Candida krusei responsible for a smaller percentage. 6
In June 2021, ibrexafungerp was approved by the Food and Drug Administration (FDA). Interestingly, this medication is fungicidal, compared with fluconazole that is fungistatic. It is dosed at 300 mg by mouth twice in 1 day. It does not cause liver toxicity and its activity is not impacted by a low vaginal pH. It is active against C. glabrata. Ibrexafungerp is contraindicated during pregnancy.
The International Society for the Study of Vulvovaginal Disease (ISSVD) has an app (The Vulvovaginal Candidiasis [Candida, Yeast]: Tips for Diagnosis and Treatment app, available on iPhone) that provides guidance for treatment of RCVV by species. This underscores the importance of not only confirming yeast as the cause of the disorder, but also identifying the species before initiating long-term therapy.
Additional considerations for management of women with RCVV include exploring and altering or eliminating factors that may promote the infection. This may include removing intrauterine devices in some women, improved control of diabetes, and optimizing immunocompromised states. Review of medications, with elimination of sodium glucose cotransporter two inhibitors (which promote glycosuria) if possible, and minimizing, when feasible, use of corticosteroids and antibiotics may be helpful in long-term control of RCVV.
Materials and Methods
A panel of vulvovaginal experts was convened by the sponsors (Prestige Consumer Healthcare), based on their clinical and research experience, to develop a consensus article on recommendation for topical dosing in RVVC maintenance. Before the meeting, participants were encouraged to review the CDC guidelines and the ISSVD consensus guidelines. They were also expected to be up to date on the peer-reviewed literature and perform a literature review for the treatment of RVCC.
Results
Review of available data suggests that clotrimazole, miconazole, terconazole, and intravaginal boric acid are the suggested interventions for RVVC caused by Candida albicans. Nystatin ovules remain an option for treatment in most cases of RVVC, but the CDC states that azoles may be more effective 3 , 7––9 (Table 2). In addition, nystatin ovules are currently not available in the United States and need to be compounded by specialty pharmacies. For nonalbicans RVVC, the same interventions were recommended, although some experts felt a nonterconazole azole should be used unless prior response to terconazole has been demonstrated (Table 3).
Table 2.
Recommendations: Topical Drugs and Dosing Regimens for Maintenance Recurrent Vulvovaginal Candidiasis (Candida albicans)
| Management options |
| Three-day treatments (azoles): clotrimazole 2% cream; miconazole 4% cream/200 mg suppositories/200 mg ovule; terconazole 0.8% cream |
| Seven-day treatments (azoles): clotrimazole 1% cream; miconazole 2% cream; terconazole 0.4% cream |
| Boric acid: 600 mg suppositories |
| Nystatin: 100,000-unit ointment; 100,000-unit ovules |
| Use the listed management options (6 months) 1–3 times weekly to start, then maintain or reduce frequency of dosing depending on the frequency of recurrence. |
| Most often recommendation is twice a week dosing. |
| If using a 3-day strength formulation, consider once a week dosing |
| If using a 7-day strength formulation, consider twice a week dosing |
| Notes |
| Before maintenance therapy, a full course of therapy is recommended |
| Only 7-day azoles are recommended during pregnancy |
| Patients with significant symptoms who are being treated with oral fluconazole may benefit from topical azoles (alone or in combination with a steroid) |
| Boric acid precautions should always be reviewed |
Table 3.
Recommendations Topical Drugs and Dosing Regimens Maintenance Recurrent Vulvovaginal Candidiasis (Nonalbicans Species)
| Management options |
| Three-day treatments (azoles): clotrimazole 2% cream; miconazole 4% cream/200 mg suppositories/200 mg ovule; terconazole 0.8% cream a |
| Seven-day treatments (azoles): clotrimazole 1% cream; miconazole 2% cream; terconazole 0.4% cream a |
| Boric acid 600 mg suppositories |
| Use the listed management options (6 months) 1–3 times weekly to start, then maintain or reduce frequency of dosing depending on the frequency of recurrence. |
| Most often recommendation is twice a week dosing. |
| If using a 3-day strength formulation, consider once a week dosing |
| If using a 7-day strength formulation, consider twice a week dosing |
| Notes |
| Before maintenance therapy, a full treatment course is recommended |
| Only 7-day azoles are recommended during pregnancy |
| Boric acid precautions should always be reviewed |
Some experts recommend a nonterconazole agent should be considered unless prior susceptibility to terconazole has been demonstrated.
According to this expert consensus, after the initial treatment has been completed, for recurrent infections, topical dosage and frequency should begin at one to three times weekly, then maintained or reduced in frequency of dosing depending on the frequency of recurrence. Twice a week dosing was the regimen most often utilized. Intravaginal boric acid is as an option for either C. albicans or nonalbicans species, but is not as frequently utilized in C. albicans where azole coverage is generally successful. During pregnancy, a 7-day azole is recommended for initial dosing, and boric acid, fluconazole, and ibrexafungerp should be avoided (See Supplementary Box S2). Recommendations for the effective topical agents for individual species can be found in the ISSVD VVC—yeast app (app store, ISSVD).
Discussion
Literature concerning suppressive or maintenance therapy with topical treatments is limited. Research by Fong explored the treatment of 23 women with a 500 mg dose of clotrimazole monthly with menses for 6 months versus one dose with onset of symptoms, with a crossover after 6 months. Fong showed that women treated prophylactically developed 2.2 episodes of VVC versus 3.6 in the empiric group. The women in this trial preferred symptomatic treatment only. 7 Stein et al. used terconazole 0.8% cream initially for a symptomatic episode of candida vaginitis, followed by weekly applications of 0.8% cream for 26 weeks in 22 women with RVVC.
Their data showed there were statistically significant less infections during the prophylactic period than the 26-week follow-up period (4 vs. 14). 8 A 2000 review in American Family Physician recommended clotrimazole two 100-mg tablets administered intravaginally twice weekly for 6 months or terconazole 0.8% cream one full applicator (5 g) administered vaginally once a week. 9 Since that time, in vitro studies suggest less effectiveness of terconazole against nonalbicans species, especially at physiologic pH levels. 10
Boric acid has limitations that need consideration (Supplementary Box S1). Boric acid is not FDA approved. Until recently with the introduction of OTC boric acid products, it needed to be compounded. Also, there are no long-term safety data available for vaginal use. Boric acid can be toxic if ingested orally. The National Pesticide Information Center characterizes the toxicity risk as low with the most common side effects being nausea, vomiting, and diarrhea, with fatality being rare. 11,12 Nonetheless, clinicians should advise care with storage of boric acid capsules, away from orally ingested medications and out of reach of children and pets. In addition, during use, oral sex should be avoided. Boric acid is contraindicated during pregnancy.
Recent studies have shown that at different pH values, antifungals may have different minimum inhibitory concentrations (MICs) with a lower MIC indicating better effectiveness and less resistance. In vitro testing is often at a pH of 7, whereas the normal vaginal pH is 4. When in vitro testing is performed at this lower more physiologic pH, MIC values of antifungals have been shown to be higher. 13
A 2018 retrospective analysis of 217 first positive yeast cultures from 217 patients confirmed a higher MIC for all antifungals with in vitro testing at pH 4. 10 For C. albicans the largest MIC difference was for terconazole (0.17 pH 7 vs. 6.17 pH 4) and clotrimazole (0.04 vs. 0.24). When testing antifungal MIC against C. glabrata at the lower pH (4 versus 7) terconazole was most affected (0.26 at pH 7 vs C. glabrata at the lower pH. Miconazole was least affected with MIC remaining
Although clinical correlation with these in vitro studies is limited, these data reinforce that before suppressive therapy is initiated, the agent used should be evaluated for efficacy.
The duration of suppressive therapy is generally recommended for 6 months. However, 30%–50% of women will recur after maintenance therapy is discontinued. Women who recur after initial suppression or for those who culture positive during suppressive therapy should be referred to a health care provider with experience in managing RVVC.
Conclusion
Expert consensus on for the topical treatment of RVVC supported maintenance therapy with clotrimazole, miconazole, terconazole, or boric acid caused by C. albicans. For nonalbicans RVVC, the same interventions were recommended, although some experts felt a nonterconazole azole should be used unless prior response to terconazole had been demonstrated. After the initial treatment has been completed, maintenance should begin at one to three times weekly, based on chosen agent, then maintained or reduced in frequency of dosing depending on the frequency of recurrence. Twice a week dosing was the regimen most often utilized.
These recommendations can be used to guide practicing clinicians. Although for most women fluconazole suppression will be adequate, clinical decisions should be based on identification of yeast species, patient characteristics, and concomitant medication and pregnancy plans. In some women, episodic treatment is an option, but maintenance should also be considered for this population.
Disclaimers
The views expressed in this article are those of the authors and not an official position of any of the associated institutions or the funder.
Vulvovaginal Candidiasis (VVC)
VVC usually is caused by Candida albicans but can occasionally be caused by other Candida species or yeasts. Typical symptoms of VVC include pruritus, vaginal soreness, dyspareunia, external dysuria, and abnormal vaginal discharge. None of these symptoms is specific for VVC. An estimated 75% of women will have at least one episode of VVC, and 40%–45% will have two or more episodes. On the basis of clinical presentation, microbiology, host factors, and response to therapy, VVC can be classified as either uncomplicated or complicated (Box 4). Approximately 10%–20% of women will have complicated VVC, requiring special diagnostic and therapeutic considerations.
BOX 4. Classification of vulvovaginal candidiasis (VVC)
Uncomplicated VVC
- Sporadic or infrequent VVC
- Mild-to-moderate VVC
- Likely to be Candida albicans
- Nonimmunocompromised women
Complicated VVC
- Non-albicans candidiasis
Women with diabetes, immunocompromising conditions (e.g., HIV infection), underlying immunodeficiency, or immunosuppressive therapy (e.g., corticosteroids)
Abbreviation: HIV, human immunodeficiency virus.
Uncomplicated Vulvovaginal Candidiasis
Diagnostic Considerations
A diagnosis of Candida vaginitis is clinically indicated by the presence of external dysuria and vulvar pruritus, pain, swelling, and redness. Signs include vulvar edema, fissures, excoriations, and thick curdy vaginal discharge. Most healthy women with uncomplicated VVC have no identifiable precipitating factors. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either a wet preparation (saline, 10% KOH) of vaginal discharge demonstrates budding yeasts, hyphae, or pseudohyphae, or a culture or other test yields a positive result for a yeast species. Candida vaginitis is associated with normal vaginal pH (<4.5). Use of 10% KOH in wet preparations improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae. Examination of a wet mount with KOH preparation should be performed for all women with symptoms or signs of VVC, and women with a positive result should be treated. For those with negative wet mounts but existing signs or symptoms, vaginal cultures for Candida should be considered. If Candida cultures cannot be performed for these women, empiric treatment can be considered. Identifying Candida by culture in the absence of symptoms or signs is not an indication for treatment because approximately 10%–20% of women harbor Candida species and other yeasts in the vagina. The majority of PCR tests for yeast are not FDA cleared, and providers who use these tests should be familiar with the performance characteristics of the specific test used. Yeast culture, which can identify a broad group of pathogenic yeasts, remains the reference standard for diagnosis.
Treatment
Short-course topical formulations (i.e., single dose and regimens of 1–3 days) effectively treat uncomplicated VVC. Treatment with azoles results in relief of symptoms and negative cultures in 80%–90% of patients who complete therapy.
Recommended Regimens for Vulvovaginal Candidiasis
Over-the-Counter Intravaginal Agents
Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days
Clotrimazole 2% cream 5 g intravaginally daily for 3 days
Miconazole 2% cream 5 g intravaginally daily for 7 days
Miconazole 4% cream 5 g intravaginally daily for 3 days
Miconazole 100 mg vaginal suppository one suppository daily for 7 days
Miconazole 200 mg vaginal suppository one suppository for 3 days
Miconazole 1,200 mg vaginal suppository one suppository for 1 day
Tioconazole 6.5% ointment 5 g intravaginally in a single application
Prescription Intravaginal Agents
Butoconazole 2% cream (single-dose bioadhesive product) 5 g intravaginally in a single application
Terconazole 0.4% cream 5 g intravaginally daily for 7 days
Terconazole 0.8% cream 5 g intravaginally daily for 3 days
Terconazole 80 mg vaginal suppository one suppository daily for 3 days
Oral Agent
Fluconazole 150 mg orally in a single dose
The creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information. Even women who have previously received a diagnosis of VVC by a clinician are not necessarily more likely to be able to diagnose themselves; therefore, any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms
Follow-Up
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.
Management of Sex Partners
Uncomplicated VVC is not usually acquired through sexual intercourse, and data do not support treatment of sex partners. A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms.
Special Considerations
Drug Allergy, Intolerance, and Adverse Reactions
Topical agents usually cause no systemic side effects, although local burning or irritation might occur. Oral azoles occasionally cause nausea, abdominal pain, and headache. Therapy with the oral azoles has rarely been associated with abnormal elevations of liver enzymes. Clinically important interactions can occur when oral azoles are administered with other drugs (1141).
Complicated Vulvovaginal Candidiasis
Diagnostic Considerations
Vaginal culture or PCR should be obtained from women with complicated VVC to confirm clinical diagnosis and identify non–albicans Candida. Candida glabrata does not form pseudohyphae or hyphae and is not easily recognized on microscopy. C. albicans azole resistance is becoming more common in vaginal isolates (1144,1145), and non–albicans Candida is intrinsically resistant to azoles; therefore, culture and susceptibility testing should be considered for patients who remain symptomatic.
Recurrent Vulvovaginal Candidiasis
Recurrent VVC, usually defined as three or more episodes of symptomatic VVC in 1146). Recurrent VVC can be either idiopathic or secondary (related to frequent antibiotic use, diabetes, or other underlying host factors). The pathogenesis of recurrent VVC is poorly understood, and the majority of women with recurrent VVC have no apparent predisposing or underlying conditions. C. glabrata and other non–albicans Candida species are observed in 10%–20% of women with recurrent VVC. Conventional antimycotic therapies are not as effective against these non–albicans yeasts as against C. albicans.
Treatment
Most episodes of recurrent VVC caused by C. albicans respond well to short-duration oral or topical azole therapy. However, to maintain clinical and mycologic control, a longer duration of initial therapy (e.g., 7–14 days of topical therapy or a 100-mg, 150-mg, or 200-mg oral dose of fluconazole every third day for a total of 3 doses [days 1, 4, and 7]) is recommended, to attempt mycologic remission, before initiating a maintenance antifungal regimen.
Oral fluconazole (i.e., a 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the indicated maintenance regimen. If this regimen is not feasible, topical treatments used intermittently can also be considered. Suppressive maintenance therapies are effective at controlling recurrent VVC but are rarely curative long-term (1147). Because C. albicans azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.
Severe Vulvovaginal Candidiasis
Severe VVC (i.e., extensive vulvar erythema, edema, excoriation, and fissure formation) is associated with lower clinical response rates among patients treated with short courses of topical or oral therapy. Either 7–14 days of topical azole or 150 mg of fluconazole in two sequential oral doses (second dose 72 hours after initial dose) is recommended.
Non–albicans Vulvovaginal Candidiasis
Because approximately 50% of women with a positive culture for non–albicans Candida might be minimally symptomatic or have no symptoms, and because successful treatment is often difficult, clinicians should make every effort to exclude other causes of vaginal symptoms for women with non–albicans yeast (1148). The optimal treatment of non–albicans VVC remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended. If recurrence occurs, 600 mg of boric acid in a gelatin capsule administered vaginally once daily for 3 weeks is indicated. This regimen has clinical and mycologic eradication rates of approximately 70% (1149). If symptoms recur, referral to a specialist is advised.
Management of Sex Partners
No data exist to support treating sex partners of patients with complicated VVC. Therefore, no recommendation can be made.
Special Considerations
Compromised Host
Women with underlying immunodeficiency, those with poorly controlled diabetes or other immunocompromising conditions (e.g., HIV), and those receiving immunosuppression therapy (e.g., corticosteroid treatment) might not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7–14 days) conventional treatment is necessary.
Pregnancy
VVC occurs frequently during pregnancy. Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women. Epidemiologic studies indicate a single 150-mg dose of fluconazole might be associated with spontaneous abortion (1150) and congenital anomalies; therefore, it should not be used (1151).
HIV Infection
Vaginal Candida colonization rates among women with HIV infection are higher than among women without HIV with similar demographic and risk behavior characteristics, and the colonization rates correlate with increasing severity of immunosuppression (1152). Symptomatic VVC is also more frequent among women with HIV infection and similarly correlates with severity of immunodeficiency (1153). In addition, among women with HIV, systemic azole exposure is associated with isolation of non–albicans Candida species from the vagina.
Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV. Although long-term prophylactic therapy with fluconazole 200 mg weekly has been effective in reducing C. albicans colonization and symptomatic VVC (1154), this regimen is not recommended for women with HIV infection in the absence of complicated VVC (98). Although VVC is associated with increased HIV seroconversion among HIV-negative women and increased HIV cervicovaginal levels among women with HIV infection, the effect of treatment for VVC on HIV acquisition and transmission remains unknown.
