ATC Class: G01AF15
VA Class: GU300
Chemical Name: (±)-1-[4-(4-Chlorophenyl)-2-[2,6-dichlorophenyl) thio]butyl]-1H-imidazole mononitrate
Molecular Formula: C19H17Cl3N2S•HNO3
CAS Number: 64872-77-1
Brands: Gynazole-1, Mycelex-3
Uses for Butoconazole
Treatment of uncomplicated vulvovaginal candidiasis (mild to moderate, sporadic or infrequent, most likely caused by Candida albicans, occurring in immunocompetent women).1 4 6 7 24 29 30 31 48 51 A drug of choice.7 29 34 35 36 37 39 40 41 48 51
Self-medication (OTC use) for treatment of uncomplicated vulvovaginal candidiasis in otherwise healthy, nonpregnant women who have been previously diagnosed by a clinician and are having recurrence of similar symptoms.29 47
Treatment of complicated vulvovaginal candidiasis, including infections that are recurrent (≥4 episodes in 1 year), severe (extensive vulvar erythema, edema, excoriation, fissure formation), caused by Candida other than C. albicans, or occurring in women with underlying medical conditions (uncontrolled diabetes mellitus, HIV infection, immunosuppressive therapy, pregnancy).7 29 35 36 37 41 46 Complicated infections generally require more prolonged treatment than uncomplicated infections.29 49 50
Optimal regimens for treatment of vulvovaginal candidiasis caused by Candida other than C. albicans (e.g., C. glabrata, C. krusei) not identified.29 48 CDC and others state these infections may respond to an intravaginal azole antifungal given for 7–14 days or to a 14-day regimen of intravaginal boric acid (not commercially available in the US).29 48 51
Butoconazole Dosage and Administration
Intravaginal Topical Administration
Uncomplicated Vulvovaginal Candidiasis
Uncomplicated Vulvovaginal Candidiasis
If clinical symptoms persist, tests should be repeated to rule out other pathogens, to confirm the original diagnosis, and to rule out other conditions that may predispose a patient to recurrent vaginal fungal infections.1
Complicated Vulvovaginal Candidiasis
Vulvovaginal Candidiasis in HIV-infected WomenIntravaginal
Use same intravaginal regimen recommended for women without HIV infection; however29 41 46 49 some experts recommend a duration of 3–7 days.49 Maintenance regimen of an intravaginal azole can be considered for those with recurrent episodes;49 routine primary or secondary prophylaxis (long-term suppressive or chronic maintenance therapy) not recommended.29 49
Recurrent Vulvovaginal Infections Caused by Candida albicansIntravaginal
CDC and others recommend an initial intensive regimen (7–14 days of an intravaginal azole or 3-dose regimen of oral fluconazole) to achieve mycologic remission, followed by an appropriate maintenance regimen (6-month regimen of once-weekly oral fluconazole or, alternatively, an intravaginal azole given intermittently).7 29 35 36 37 41 46 48 50
Other Complicated Vulvovaginal InfectionsIntravaginal
CDC and others recommend 7–14 days of an intravaginal azole for vulvovaginal candidasis that is severe, caused by Candida other than C. albicans, or occurring in women with underlying medical conditions.29 50
Cautions for Butoconazole
Known hypersensitivity to butoconazole or any ingredient in the formulation.1
Use of Latex or Rubber Products
Butoconazole vaginal cream contains mineral oil that can weaken latex or rubber products (including condoms and vaginal contraceptive diaphragms).1 29 47 Use of such products within 72 hours following intravaginal butoconazole treatment not recommended.1
Selection and Use of Antifungals for Vulvovaginal Candidiasis
Prior to initial use of butoconazole in a woman with signs and symptoms of vulvovaginal candidiasis, confirm the diagnosis by demonstrating yeast or pseudohyphae with direct microscopic examination of vaginal discharge (saline or 10% potassium hydroxide [KOH] wet mount or Gram stain) or by culture.1 4 5 6 24 29 31
Candida identified by culture in the absence of symptoms is not an indication for antifungal treatment since approximately 10–20% of women harbor Candida or other yeasts in the vagina.29
If clinical symptoms persist after treatment or recur within 2 months, tests should be repeated to rule out other pathogens, to confirm the original diagnosis, and to rule out other conditions that may predispose a patient to recurrent vaginal fungal infections (e.g., pregnancy, HIV infection).1 47
Do not use for self-medication in women who have never had a vaginal yeast infection diagnosed by a clinician, in women who are or think they may be pregnant, or in women with diabetes, HIV infection, or HIV exposure.47
CDC states that a 7-day regimen of an intravaginal azole antifungal can be used, if necessary, for treatment of vulvovaginal candidiasis in pregnant women.29
Not known whether intravaginal butoconazole is distributed into milk; use with caution in nursing women.1
Gynazole-1: Safety and efficacy not established in children.1
Mycelex-3: Safety and efficacy not established in children <12 years of age.47
Common Adverse Effects
Vulvar/vaginal burning, itching, soreness and swelling, pelvic or abdominal pain or cramping.1
Metabolic fate following intravaginal administration not fully characterized, but systemically absorbed drug appears to be extensively metabolized probably in the liver.4
The systemically absorbed fraction of an intravaginal dose appears to be excreted in urine and feces.4
Actions and Spectrum
Presumably exerts its antifungal activity by altering cellular membranes,1 8 9 17 22 resulting in increased membrane permeability, secondary metabolic effects, and growth inhibition.1 9 17 22 Interferes with ergosterol synthesis probably via inhibition of C-14 demethylation of sterol intermediates (e.g., lanosterol).1 3 9 16 17
Dermatophytes and other fungi: Active in vitro against Trichophyton concentricum, T. mentagrophytes, T. rubrum, T. tonsurans, Epidermophyton floccosum, Microsporum canis, and M. gypseum.15 23 Also active in vitro against Aspergillus2 and Cryptococcus.23
Cross-resistance can occur among the azole antifungals.2
Advice to Patients
Not for self-medication in women who have never had a vaginal yeast infection diagnosed by a clinician.47
Importance of discontinuing self-medication of vulvovaginal candidiasis and consulting clinician if fever, abdominal pain, or foul-smelling vaginal discharge develops; if symptoms do not improve within 3 days; if condition persists after therapy; or if symptoms recur within 2 months.29 47
Importance of not using latex or rubber products such as condoms or vaginal contraceptive diaphragms within 72 hours following butoconazole treatment.1
If used during menstruation, importance of using sanitary napkins instead of vaginal tampons.47
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and concomitant illnesses.1
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Gynazole-1 (with parabens, propylene glycol, and microcrystalline wax; available with prefilled, disposable applicators)
Mycelex-3 (with parabens and propylene glycol; available with or without disposable applicators)
AHFS DI Essentials. © Copyright 2017, Selected Revisions August 1, 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.
1. Ther-Rx Corporation. Gynazole-1 (butoconazole nitrate) vaginal cream prescribing information (dated 2003 Aug). In: Physicians’ desk reference. From the PDR electronic library website (http://pdrel.thomsonhc.com). Accessed 2006 Dec 4.
2. Odds FC, Webster CE, Abbott AB. Antifungal relative inhibition factors: BAY 1-9139, bifonazole, butoconazole, isoconazole, itraconazole (R 51211), oxiconazole, Ro 14-4767/002, sulconazole, terconazole and vibunazole (BAY n-7133) compared in vitro with nine established antifungal agents. J Antimicrob Chemother. 1984; 14:105-14. [PubMed 6094418]
3. Pye GW, Marriott MS. Inhibition of sterol C14 demethylation by imidazole-containing antifungals. Sabouraudia. 1982; 20:325-9. [PubMed 6760419]
4. Droegemueller W, Adamson DG, Brown D et al. Three-day treatment with butoconazole nitrate for vulvovaginal candidiasis. Obstet Gynecol. 1984; 64:530-4. [IDIS 191594] [PubMed 6384848]
5. Jacobson JB, Hajman AJ, Wiese J et al. A new vaginal antifungal agent—butoconazole nitrate. Acta Obstet Gynecol Scand. 1985; 64:241-4. [PubMed 3893024]
6. Bradbeer CS, Mayhew SR, Barlow D. Butoconazole and miconazole in treating vaginal candidiasis. Genitourin Med. 1985; 61:270-2. [PubMed 3894216]
7. Anon. Drugs for vulvovaginal candidiasis. Med Lett Drugs Ther. 2001; 43:3-4. [PubMed 11151090]
8. Beggs WH. Influence of growth phase on the susceptibility of Candida albicans to butoconazole, oxiconazole, and sulconazole. J Antimicrob Chemother. 1985; 16:397-9. [PubMed 3902762]
9. Beggs WH, Andrews FA, Sarosi GA. Minireview: action of imidazole-containing antifungal drugs. Life Sci. 1981; 28:111-8. [PubMed 7019609]
10. Arya VP. Butoconazole nitrate: antifungal agent. Drugs Future. 1979; 4:89-91.
13. Heiberg JK, Svejgaard E. Toxic hepatitis during ketoconazole treatment. BMJ. 1981; 283:825-6. [IDIS 138588] [PubMed 6271328]
14. Janssen. Nizoral (ketoconazole) tablets prescribing information (dated 1998 Jul). In: Huff BB, ed. Physicians’ desk reference. 56th ed. Montvale, NJ: Medical Economics Company Inc; 2002:1791-2.
15. Walker KAM, Braemer AC, Hitt S et al. 1-[4-(4-Chlorophenyl)-2-(2,6-dichlorophenylthio)-n-butyl]-1H-imidazole nitrate, a new potent antifungal agent. J Med Chem. 1978; 21:840-3. [PubMed 357722]
16. Sud IJ, Feingold DS. Mechanisms of action of the antimycotic imidazoles. J Invest Dermatol. 1981; 76:438-41. [IDIS 133194] [PubMed 7017013]
17. Borgers M. Mechanism of action of antifungal drugs, with special reference to the imidazole derivatives. Rev Infect Dis. 1980; 2:520-34. [IDIS 124096] [PubMed 7003674]
18. Sobel JD. Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol. 1985; 152(7 Part 2):924-35. [PubMed 3895958]
20. Adamson GD, Brown D Jr, Standard JV et al. Three-day treatment with butoconazole vaginal suppositories for vulvovaginal candidiasis. J Reprod Med. 1986; 31:131-2. [PubMed 3514908]
22. Thomas AH. Suggested mechanisms for the antimycotic activity of the polyene antibiotics and the N-substituted imidazoles. J Antimicrob Chemother. 1986; 17:269-79. [PubMed 3516967]
23. Matthews T. Butoconazole: pharmacologic considerations, chemistry and microbiology. J Reprod Med. 1986; 31(Suppl):655-7.
24. Van Dyck WA Jr. A comparative study of butoconazole, miconazole and placebo. J Reprod Med. 1986; 31(Suppl):662-3.
26. Reviewers’ comments (personal observations); 1986 Jul.
27. Bergan T, Vangdal M. In vitro activity of antifungal agents against yeast species. Chemotherapy. 1983; 29:104-10. [IDIS 169053] [PubMed 6301773]
29. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recomm Rep. 2006; 55(No. RR-11):1-85.
30. Anon. Drugs for sexually transmitted infections. Treat Guidel Med Lett. 2004; 2:67-74. [PubMed 15529116]
31. Doering PL, Santiago TM. Drugs for treatment of vulvovaginal candidiasis: comparative efficacy of agents and regimens. DICP. 1990; 24:1078-83. [IDIS 274670] [PubMed 2275233]
32. Sobel JD. Pathogenesis and treatment of recurrent vulvovaginal candidiasis. Clin Infect Dis. 1992; 14(Suppl 1):S148-53.
34. Hay RJ. Yeast infections. Dermatol Clin. 1996; 14:113-24. [PubMed 8821164]
35. Doering PL, Santiago TM. Drugs for the treatment of vulvovaginal candidiasis: comparative efficacy of agents and regimens. DICP. 1990; 24:1078-83. [IDIS 274670] [PubMed 2275233]
36. Sobel JD. Vaginitis. N Engl J Med. 1997; 337:1896-903. [IDIS 401347] [PubMed 9407158]
37. Sobel JD, Faro S, Force RW et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol. 1998; 178:203-11. [IDIS 402301] [PubMed 9500475]
38. Bisschop MPJM, Merkus JMWM, Scheygrond H et al. Co-treatment of the male partner in vaginal candidosis: a double-blind randomized control study. Br J Obstet Gynecol. 1986; 93:79-81.
39. Bohannon NJV. Treatment of vulvovaginal candidiasis in patients with diabetes. Diabetes Care. 1998; 21:451-6. [IDIS 402373] [PubMed 9540031]
40. Tobin MJ. Vulvovaginal candidiasis: topical vs. oral therapy. Am Fam Physician. 1995; 51:1715-24. [IDIS 348350] [PubMed 7754931]
41. Sobel JD. Controversial aspects in the management of vulvovaginal candidiasis. J Am Acad Dermatol. 1994; 31: S10-3. [IDIS 335764] [PubMed 8077494]
42. Spinillo A, Capuzzo E, Gulminetti R et al. Prevalence of and risk factors for fungal vaginitis caused by non-albicans species. Am J Obstet Gynecol. 1997; 176: 138-41. [PubMed 9024104]
43. Chaim W. Fungal vaginitis caused by nonalbicans species. Am J Obstet Gynecol. 1997; 177: 485. [IDIS 393344] [PubMed 9290485]
44. Spinillo A, Capuzzo E. Fungal vaginitis caused by nonalbicans species. Am J Obstet Gynecol. 1997; 177: 485-6.
45. Redondo-Lopez V, Lynch M, Schmitt C et al. Torulopsis glabrata vaginitis: clinical aspects and susceptibility to antifungal agents. Obstet Gynecol. 1990; 76: 651-5.
46. Reviewers’ comments (personal observations) on Tioconazole 84:04.08.
47. Mycelex-3 Vaginal Cream product information. From BayerCare.com (.) Accessed 2006 Dec 4.
48. Pappas GP, Rex JR, Sobel JD et al. Guidelines for treatment of candidiasis. Clin Infect Ids. 2004; 38:161-89.
49. Centers for Disease Control and Prevention. Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. MMWR Recomm Rep. 2004; 53(RR-15):1-112.
50. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, number 72, May 2006: vaginitis. Obste Gynecol. 2006; 107:1195-296.
51. Anon. Antifungal drugs. Treat Guidel Med Lett. 2005; 3:7-14. [PubMed 15671963]
b. AHFS Drug Information 2005. McEvoy, GK, ed. Butoconazole nitrate. Bethesda, MD: American Society of Health-System Pharmacists; 2005.
More about butoconazole topical
- Other brands: Gynazole-1