Guideline sources The following summarized guidelines for the evaluation and management of vulvovaginal candidiasis (VVC) are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2021), the American College of Obstetricians and Gynecologists (ACOG 2020), the International Union Against Sexually Transmitted Infections (IUSTI/WHO 2018), the Infectious Diseases Society of America (IDSA 2016), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2015), and the AIDSinfo Society (AIDSInfo 2009). 1 2 3 4 5 6 Guidelines 1. Screening and diagnosis Diagnosis: as per IUSTI 2018 guidelines, obtain microscopy as the current best test for the diagnosis of VVC. B 2. Medical management Antifungal therapy (agents): Recognize that OTC intravaginal agents for VVC include: Situation Guidance https://web.pathway.md/diseases/recNlRUXPM5tZlO66 1/5 6/29/23, 3:45 AM Vulvovaginal candidiasis Pathway Clotrimazole 1% cream 5 g intravaginally daily for 7-14 days 2% cream 5 g intravaginally daily for 3 days 2% cream 5 g intravaginally daily for 7 days Miconazole 4% cream 5 g intravaginally daily for 3 days 100 mg vaginal suppository one suppository daily for 7 days 200 mg vaginal suppository one suppository for 3 days 1,200 mg vaginal suppository one suppository for 1 day 6.5% ointment 5 g intravaginally in a single application. E Tioconazole Recognize that prescription drugs for VVC include: Situation Guidance 2% cream (single-dose bioadhesive product) 5 g intravaginally in a single application Butoconazole 0.4% cream 5 g intravaginally daily for 7 days Terconazole 0.8% cream 5 g intravaginally daily for 3 days 80 mg vaginal suppository one suppository daily for 3 days 150 mg PO in a single dose. E Fluconazole Antifungal therapy, uncomplicated disease: As per WHO/IUSTI 2018 guidelines, administer a single-dose azole (oral or vaginal) for the treatment of patients with uncomplicated VVC. A As per IDSA 2016 guidelines: Administer topical antifungal agents as first-line therapy in patients with uncomplicated VVC. Recognize that no one agent has been shown superior to another. A Administer a single 150 mg oral dose of fluconazole as an alternative option in patients with uncomplicated VVC. A As per SOGC 2015 guidelines: https://web.pathway.md/diseases/recNlRUXPM5tZlO66 2/5 6/29/23, 3:45 AM Vulvovaginal candidiasis Pathway Recognize that topical and oral antifungal azole medications are equally effective for the treatment of patients with VVC. A Recognize that symptomatic VVC treated with topical azoles may require longer courses of therapy. A Antifungal therapy (severe disease): administer fluconazole 150 mg PO every 72 hours, a total of 2-3 doses, in patients with severe acute VVC. A Management of recurrence: As per IUSTI 2018 guidelines, administer a 3-day induction course of an azole followed by long-term maintenance suppressive regimen for at least 6 months in patients with persistent and recurrent VVC. B As per IDSA 2016 guidelines, administer induction therapy with a topical agent or oral fluconazole for 10-14 days, followed by fluconazole 150 mg weekly for 6 months in patients with recurrent VVC. A As per SOGC 2015 guidelines: Diagnose recurrent VVC in patients with 4 episodes per year. B Administer maintenance therapy with weekly oral fluconazole following initial therapy to enhance treatment success in patients with recurrent VVC. B 3. Specific circumstances Pregnant patients: administer topical azole preparations for the treatment of VVC in pregnant patients. B Patients with C. glabrata infection: consider administering topical intravaginal boric acid, administered in a gelatin capsule, for 14 days as an alternative in patients with C. glabrata vulvovaginitis unresponsive to oral azoles. B Patients with HIV: Administer short-course oral or topical treatment with any of the following regimens in human immunodeficiency virus-infected patients with VVC: a single dose of oral fluconazole 150 mg B topical azoles, such as clotrimazole, butoconazole, miconazole, tioconazole, or terconazole for 3-7 days B oral itraconazole 200 mg daily for 3-7 days. B Administer oral fluconazole 100-200 mg or topical antifungals for 7 days in human immunodeficiency virus-infected patients with severe or recurrent VVC. B Clinical findings Symptoms Past medical history Dyspareunia Antibiotics No history of vaginal odor Diabetes mellitus Vaginal discharge https://web.pathway.md/diseases/recNlRUXPM5tZlO66 3/5 6/29/23, 3:45 AM Vulvovaginal candidiasis Pathway Vaginal irritation Human immunodeficiency virus infection Vaginal itching Immunocompromising condition Vaginal pain Gynecologic exam Medication history Vaginal discharge Hormonal contraceptives Vaginal dryness Lab findings Vaginal rash Vulvar excoriations vaginal fluid pH Vulvar fissures Vulvar swelling Cytological findings Likelihood Ratios Pertinent positives The following findings increase the probability of vulvovaginal candidiasis in adults. 6 7 Finding LR+ Value Presence of yeast forms 4.8 (2.7-8.4) Increased vaginal fluid pH (> 4.5) 2.7 No history of vaginal odor 2.2 (1.9-2.5) History of vaginal itching 1.5 (1.3-1.8) Pertinent negatives The following findings decrease the probability of vulvovaginal candidiasis in adults. 6 7 Finding LR- Value History of vaginal odor 0.29 (0.20-0.43) No history of vaginal itching 0.53 (0.33-0.86) vaginal fluid pH not increased ( 4.5) 0.54 Absence of yeast forms 0.78 (0.71-0.85) References 1. Sherrard J, Wilson J, Donders G et al. 2018 European IUSTI/WHO International Union against sexually transmitted infections IUSTI World Health Organisation WHO guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov;29 13 1258 1272. Open 2. No authors listed. Vaginitis in Nonpregnant Patients: ACOG Practice Bulletin, Number 215. Obstet Gynecol. 2020 Jan;135 1):e1-e17. Open 3. Pappas PG, Kauffman CA, Andes DR et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62 4):e1 50. Open https://web.pathway.md/diseases/recNlRUXPM5tZlO66 4/5 6/29/23, 3:45 AM Vulvovaginal candidiasis Pathway 4. Kimberly A Workowski, Laura H Bachmann, Philip A Chan et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70 4 1 187. Open 5. van Schalkwyk J, Yudin MH, INFECTIOUS DISEASE COMMITTEE. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015 Mar;37 3 266 274. Open 6. Kaplan JE, Benson C, Holmes KK et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009 Apr 10;58 RR 4 1 207. Open 7. Bornstein J, Lakovsky Y, Lavi I et al. The classic approach to diagnosis of vulvovaginitis: a critical analysis. Infect Dis Obstet Gynecol. 2001;9 2 105 11. Open 8. Simel D, Rennie D. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Mayo Clin Proc. 2009 Nov; 84 11 1045. Open 9. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC et al. 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