4. What is the management for this case?

For the treatment of vulvovaginal candidiasis, the Center for Disease control (CDC) recommends placing the woman into an uncomplicated or complicated category to guide treatment. In this case, the patient can be classified under the uncomplicated category.

A number of azole vaginal preparations and a single oral agent, fluconazole, are approved for treatment. In patients with uncomplicated vulvovaginal candidiasis, topical antifungal agents are typically used for 1 to 3 days, or a single oral dose of fluconazole. Patient preference, response to prior therapy, and cost should guide the choice of therapy.

For patients with complicated vaginitis, topical azoles are recommended for 7 to 14 days. If using oral therapy, a second dose of fluconazole (150 mg) given 72 hours after the first dose is recommended.

In women with recurrent vulvovaginal candidiasis, the resolution of symptoms typically requires longer duration of therapy. Seven to 14 days of topical therapy or three doses of oral fluconazole 3 days apart (e.g., days 1, 4, and 7) are options. After this initial treatment, maintenance therapy will help prevent recurrence of symptoms. Oral fluconazole (e.g., 100-, 150-, or 200-mg dose) weekly for 6 months is typically first-line treatment. However, topical treatments used intermittently as a maintenance regimen may be considered. Women with

recurrent vulvovaginitis should receive a vaginal fungal culture to determine species and sensitivities.

Infections with Candida spp. other than C. albicans are often azole-resistant. However, one study of terconazole for non– C. albicans fungal vaginitis resulted in a mycologic cure in 56% of patients and a symptomatic cure in 44% of women. Vaginal boric acid capsules (600 mg in O gelatin capsules) are another option. In one study, treatment for a minimum of 14 days resulted in a symptomatic cure rate of 70% for women with non–C. albicans infection. Boric acid inhibits fungal cell wall growth. It may also be used for suppression in women with recurrent vulvovaginal candidiasis. Following 10 days of therapy, one 600-mg capsule intravaginally twice weekly for 4 to 6 months decreases symptomatic recurrences. Boric acid is toxic if ingested, so it should be stored in a safe manner.

Studies of alternative therapies for vulvovaginal candidiasis (such as oral or vaginal Lactobacillus, garlic, or diet alterations such as yogurt ingestion) do not show efficacy.

Below is the summary of treatment options provided for Candidiasis recommended by CDC.