Medication Summary
Vulvovaginal candidiasis
In considering treatment for vulvovaginal candidiasis, distinguishing between sporadic or recurrent episodes of the disease is of great importance. Most strains of C albicans, the usual cause of uncomplicated sporadic vulvovaginal candidiasis, are sensitive to azole-based antifungal agents and are therefore usually responsive to all forms of antifungal therapy.
Atrophic vaginitis
Atrophic vaginitis is usually treated with topical vaginal estrogen for 1-2 weeks to alleviate symptoms. Treatment is then continued at decreased intervals for maintenance. An oral estrogen regimen can also be used.
Vulvar vestibulitis
Since no specific cure is available for vulvar vestibulitis, treatment should focus on the alleviation of symptoms.
Contact dermatitis
Hydrocortisone (0.5-1%) and fluorinated corticosteroids in lotions or creams may help to reduce symptoms of contact dermatitis. These medications are usually most effective against true allergic reactions.
Antifungals, Vaginal
Class Summary
These agents are used to treat vulvovaginal candidiasis. Topical azole antifungals achieve cure rates of 85-95%. Nystatin demonstrates a 75-80% cure rate. Oral fluconazole or ibrexafungerp have cure rate comparable to topical azole antifungals. [55] These may be preferred by patients because of the ease of 1-time dosing.
Intravaginal and topical therapies with a variety of antifungals, such as clotrimazole, miconazole, terconazole, and tioconazole, are highly effective. Many of the preparations are now available OTC. 1-, 3-, and 7-day regimens can be used. Cure rates of 90% are reported with longer courses.
Butoconazole (Gynazole-1)
Butoconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Tioconazole (Vagistat-1, Monistat-1)
This is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Clotrimazole (Desenex, Gyne-Lotrimin 3, Clotrimazole 3 Day)
Clotrimazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Miconazole vaginal (Vagistat 3, Miconazole 7)
Miconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Terconazole (Terazol 3, Terazol 7, Zazole)
Terconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Ketoconazole topical (Xolegel 2%)
Ketoconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Nystatin
Nystatin is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Antifungals, Systemic
Class Summary
Oral azole and triterpenoid antifungals may be considered for single day treatment regimens. Oral antifungals are contraindicated for pregnant females.
Fluconazole (Diflucan)
Fluconazole is a synthetic oral azole antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.
Ibrexafungerp (Brexafemme)
Inhibits glucan synthase, an enzyme involved in the formation of 1,3-beta-D-glucan, an essential component of the fungal cell wall. It is indicated for vulvovaginal candidiasis (VVC) and reduces the incidence of recurrent VVC in adult and postmenarchal females.
Oteseconazole (Vivjoa)
Azole metalloenzyme inhibitor that targets fungal sterol 14-alpha demethylase (CYP51). Inhibition of CYP51 results in accumulation of 14-methylated sterols, which may be toxic to fungi. It is indicated to reduce incidence of recurrent vulvovaginal candidiasis (RVVC) in females with history of RVVC who are NOT of reproductive potential.
Corticosteroids
Class Summary
These agents are used to treat extreme vaginal pruritus. Cream is for symptomatic relief, especially in pediatric vulvovaginitis.
Hydrocortisone topical (Anti-itch Maximum Strength, Itch-X)
Because of its mineralocorticoid activity and glucocorticoid effects, this is the drug of choice in treating pruritus in vulvovaginitis. The primary therapeutic effects of topical corticosteroids result from their anti-inflammatory activity, which is nonspecific (ie, they act against most causes of inflammation, including mechanical, chemical, microbiologic, and immunologic). Do not use very high-strength or high-potency agents on the face, groin, or axilla.
Estrogens
Class Summary
These agents are used in the treatment of atrophic vaginitis in postmenopausal women. Oral estrogen replacement also is effective and has other health benefits.
Conjugated estrogens (Premarin)
Several topical steroid preparations are available, including equine estrogen, estradiol, and dienestrol. Estrogens are indicated for atrophic vaginitis and atrophic urethritis associated with menopause.
Estrogen Receptor Antagonists
Class Summary
These agents competitively bind to estrogen receptors, producing a nuclear complex that decreases deoxyribonucleic acid (DNA) synthesis and inhibits estrogen effects.
Tamoxifen (Soltamox)
Tamoxifen may be used for women who are very concerned about estrogen exposure. It can act as either an estrogenic antagonist or agonist, depending on the target tissue.
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Candida albicans photomicrograph. Courtesy of Centers for Disease Control and Prevention (CDC).
Tables
Option |
Treatment |
Butoconazole |
2% cream, 5 g intravaginally for 3 days |
Butoconazole |
2% cream, 5 g (butoconazole 1-sustained release), single intravaginal application |
Clotrimazole |
1% cream, 5 g intravaginally for 7–14 days |
Clotrimazole |
100 mg vaginal tablet for 7 days |
Clotrimazole |
100 mg vaginal tablet, 2 tablets for 3 days |
Miconazole |
2% cream 5 g intravaginally for 7 days |
Miconazole |
100 mg vaginal suppository, 1 suppository for 7 days |
Miconazole |
200 mg vaginal suppository, 1 suppository for 3 days |
Miconazole |
1200 mg vaginal suppository, 1 suppository for 1 day |
Nystatin |
100,000-unit vaginal tablet, 1 tablet for 14 days |
Tioconazole |
6.5% ointment 5 g intravaginally in a single application |
Terconazole |
0.4% cream 5 g intravaginally for 7 days |
Terconazole |
0.8% cream 5 g intravaginally for 3 days |
Terconazole |
80 mg vaginal suppository, 1 suppository for 3 days |
Fluconazole |
150 mg oral tablet, 1 tablet in single dose |
| Ibrexafungerp | 150 mg oral tablet, 2 tablets (300 mg) BID x 2 doses |
