A. Vulvovaginal Candidiasis
A variety of topical and oral regimens are available to treat vulvovaginal candidiasis. Women with uncomplicated vulvovaginal candidiasis will usually respond to a 1- to 3-day regimen of a topical azole or a one-time dose of oral fluconazole. Women with complicated infection (including four or more episodes in 1 year [recurrent vulvovaginal candidiasis], severe signs and symptoms, non-albicans species, uncontrolled diabetes, HIV infection, corticosteroid treatment, or pregnancy) should receive 7–14 days of a topical regimen or two doses of oral fluconazole 3 days apart. In recurrent non-albicans infections, 600 mg of boric acid in a gelatin capsule intravaginally once daily for 2 weeks is approximately 70% effective. If recurrence occurs, referral to a gynecologist or an infectious disease specialist is indicated.
Effective single-dose regimens include miconazole (1200-mg vaginal suppository), tioconazole (6.5% cream, 5 g vaginally), sustained-release butoconazole (2% cream, 5 g vaginally), or fluconazole (150-mg oral tablet).
Effective 3-day regimens include butoconazole (2% cream, 5 g vaginally once daily), clotrimazole (2% cream, 5 g vaginally once daily), terconazole (0.8% cream, 5 g, or 80-mg vaginal suppository once daily), or miconazole (200-mg vaginal suppository once daily).
The following regimens are given once daily: clotrimazole (1% cream), miconazole (2% cream, 5 g, or 100-mg vaginal suppository), or terconazole (0.4% cream, 5 g).
An effective 14-day regimen is nystatin (100,000-unit vaginal tablet once daily).
5. Recurrent vulvovaginal candidiasis (maintenance therapy)
Clotrimazole (500-mg vaginal suppository once weekly or 200 mg cream twice weekly) or fluconazole (100, 150, or 200 mg orally once weekly) is an effective regimen for maintenance therapy for up to 6 months.
B. Trichomonas vaginalis Vaginitis
Treatment of both partners simultaneously is recommended; metronidazole or tinidazole, 2 g orally as a single dose or 500 mg orally twice a day for 7 days, is usually used.
In the case of treatment failure with metronidazole in the absence of reexposure, the patient should be re-treated with metronidazole, 500 mg orally twice a day for 7 days, or tinidazole, 2 g orally as a single dose. If treatment failure occurs again, give metronidazole or tinidazole, 2 g orally once daily for 5 days. If this is not effective in eradicating the organisms, metronidazole and tinidazole susceptibility testing can be arranged with the Centers for Disease Control and Prevention (CDC) at 404-718-4141 or at https://www.cdc.gov/std. Women infected with T vaginalis are at increased risk for concurrent infection with other sexually transmitted diseases (STDs) and should be offered comprehensive STD testing.
The recommended regimens are metronidazole (500 mg orally, twice daily for 7 days), clindamycin vaginal cream (2%, 5 g, once daily for 7 days), or metronidazole gel (0.75%, 5 g, twice daily for 5 days). Alternative regimens include clindamycin (300 mg orally twice daily for 7 days), clindamycin ovules (100 g intravaginally at bedtime for 3 days), tinidazole (2 g orally once daily for 3 days), or tinidazole (1 g orally once daily for 7 days). The National STD Curriculum offers a helpful training module to clinicians to review current recommendations for treatment of vaginitis. Continuing medical education, continuing nursing education, and continuing education units are available with this online training (https://www.std.uw.edu/custom/self-study/vaginitis).
et al. Bacterial vaginosis and desquamative inflammatory vaginitis. N Engl J Med. 2019 Mar 14;380(11):1088–9.