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Evidence summaries

Treatments for Vulvovaginal Candidiosis

Both topical and oral azoles are effective in the treatment of vulvovaginal candidiosis. Nystatin is not as effective. Level of evidence: "A"

A Cochrane review [Abstract] 1 included 26 studies with a total of 5007 participants. The antifungals studied included fluconazole and itraconazole (oral), and butoconazole, clotrimazole, econazole, miconazole and terconazole (intra-vaginal). No statistically significant differences were shown between oral and intra-vaginal anti-fungal treatment for clinical cure at short term (OR 1.14, 95% CI 0.91 to 1.43; 13 trials; n=1859) and long term (OR 1.07, 95% CI 0.77 to 1.50; 9 trials; n=1042). Oral treatment was slightly better for mycological cure at short term (OR 1.24, 95% CI 1.03 to 1.50: 19 trials; n=3057) and long term (OR 1.29, 95% CI 1.05 to 1.60; 13 trials; n=1661).

A systematic review 3 assessed the effects of drug treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women. Intravaginal imidazoles (butoconazole, clotrimazole, miconazole) reduced symptoms compared with placebo: In RCT with 790 women, 31/95 (33%) with butoconazole 2% for 3 days (intravaginal cream) had persistent symptoms at 30 days versus 31/96 (32%) with butoconazole 2% for 6 days (intravaginal cream), 34/95 (36%) with miconazole 2% for 3 days (intravaginal cream), and 45/70 (64%) with placebo. Intravaginal imidazoles had similar efficacy compared with each other (12% with terconazole, 16% with terconazole, and 19% with miconazole had symptom or mycological failure in 7 days, n=900). Intravaginal imidazoles and oral imidazoles were equally effective at achieving clinical cure: Short-term follow-up 515 days: 673/924 (73%) with intravaginal imidazoles 627/849 (74%) with oral fluconazole or oral itraconazole, OR 0.94 95% CI 0.75 to 1.17; and long-term follow-up 212 weeks 553/723 (76%) with intravaginal imidazoles 467/585 (81%) with oral fluconazole or oral itraconazole, OR 1.07 95% CI 0.82 to 1.41.

Another systematic review 2 including 26 studies of topical therapy for non-pregnant women, 15 studies of oral therapy in non-pregnant women, 6 studies of topical therapy in pregnant women, and 5 studies of therapy for recurrent disease was abstracted in DARE. The optimal treatment for vulvovaginal candidiasis (VVC) has not yet been established. Topical therapy with clotrimazole for r.ecurrent VVC causes no toxicity but is followed more often by relapses. Oral treatments can be associated with some gastrointerstinal symptoms and headaches. Trials have found the topical imidazole antifungal agents clotrimazole, micinazole, and butoconazole to be effective for the treatment of acute VVC in pregnant women. Terconazole has also been found to be effective and safe. The efficacy of nystatin ranted from 14% to 53% and was considerably lower than those for the topical azoles which ranged from 71% to 84%. Oral therapy is approximately as effective as topical therapy in non-pregnant women.

    References

    • Denison HJ, Worswick J, Bond CM et al. Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev 2020;(8):CD002845. [PubMed]
    • Martin Lopez JE. Candidiasis (vulvovaginal. BMJ Clin Evid. 2015 Mar 16;2015. pii: 0815.
    • Reef SE, Levine WC, McNeil MM, Fisher-Hoch S, Holmberg SD, Duerr A, Smith D, Sobel JD, Pinner RW. Treatment options for vulvovaginal candidiasis, 1993. Clin Infect Dis 1995 Apr;20 Suppl 1:S80-90. [PubMed][DARE]

Primary/Secondary Keywords