1. Boric acid vaginal capsules / suppositories.(vaginal)
2. Amphotericin B (vaginal cream).
3. Topical non‐fluconazole azoles (e.g. clotrimazole, miconazole, perhaps ketoconazole or itraconazole if susceptibility allows).
4. Oral systemic agents: Possibly itraconazole, voriconazole (where sensitivity allows).
5. Newer / investigational antifungals (e.g. ibrexafungerp, oteseconazole) - limited availability in UK or under trial.
Practical & safety considerations
Availability: Some treatments (e.g. boric acid vaginal therapy, amphotericin vaginal formulations) may require compounding pharmacies, be off-label, or not routinely stocked.
Safety in pregnancy: Many of the alternatives are contraindicated or not well studied during pregnancy (e.g. boric acid).
Risk of irritation: Topical treatments like amphotericin/boric acid can irritate vulval skin.
Culture & sensitivity testing: Very important. Confirm C. krusei and test what the strain is sensitive to. This helps pick an agent likely to work.
Duration & dosing: May require longer courses than for ordinary C. albicans; sometimes higher doses; sometimes repeated applications.
Referral: If first line alternative treatments fail, referral to specialist services is often advised.
