What is the likely diagnosis and appropriate treatment for a woman presenting with white, egg‑white‑like vaginal discharge?

White Egg-White Vaginal Discharge: Likely Vulvovaginal Candidiasis

This presentation is most consistent with vulvovaginal candidiasis (VVC), and you should treat with either a single 150 mg oral dose of fluconazole or a short-course topical azole antifungal. 1, 2

Clinical Diagnosis

The white, egg-white or "curd-like" discharge you describe is the classic presentation of VVC, which affects 75% of women at least once in their lifetime 3, 4. However, do not rely on discharge appearance alone—the diagnosis requires confirmation because these symptoms overlap significantly with other conditions 5.

Key Diagnostic Features to Assess:

• Vaginal pH: Should be ≤4.5 (normal) in VVC 3, 4
• Associated symptoms: Look for vulvovaginal pruritus (itching), vulvar erythema, burning, dyspareunia, or external dysuria 3, 4
• Microscopy: Wet mount with 10% KOH should demonstrate yeasts or pseudohyphae 3, 4

Critical caveat: If pH is >4.5, consider bacterial vaginosis or trichomoniasis instead. If microscopy is negative but symptoms persist, obtain a fungal culture 4.

Treatment Approach

For Uncomplicated VVC (First Episode or Sporadic):

Oral therapy (easiest):

• Fluconazole 150 mg single oral dose 1, 2

Topical alternatives (equally effective):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days (OTC) 3
• Miconazole 2% cream 5g intravaginally for 7 days (OTC) 3
• Single-dose options: Clotrimazole 500mg vaginal tablet or Tioconazole 6.5% ointment 3

All azole regimens achieve 80-90% cure rates 3. The most recent IDSA guidelines prioritize single-dose fluconazole for convenience and equivalent efficacy 1, 2.

For Severe or Complicated VVC:

If symptoms are severe (extensive vulvar erythema, edema, excoriation, fissures), use:

• Fluconazole 150 mg every 72 hours for 2-3 doses 2
• OR topical azole therapy for 7-14 days 3

For Recurrent VVC (≥4 episodes/year):

This requires extended therapy:

• Induction: 10-14 days of topical or oral azole
• Maintenance: Fluconazole 150 mg weekly for 6 months 1, 2

Important Clinical Pitfalls

1. Do not treat asymptomatic colonization: 10-20% of women harbor Candida without symptoms—this does not require treatment 3

2. OTC self-treatment is appropriate ONLY if:

   • Previously diagnosed with VVC by a clinician
   • Experiencing identical recurrent symptoms
   • If symptoms persist after OTC treatment or recur within 2 months, medical evaluation is mandatory 3

3. Consider non-albicans species if treatment fails: C. glabrata is increasingly common and often azole-resistant. For confirmed C. glabrata:

   • Boric acid 600 mg intravaginal gelatin capsule daily for 14 days 1, 2
   • OR Nystatin 100,000-unit suppository daily for 14 days 2

4. Oil-based creams and suppositories weaken latex condoms and diaphragms—counsel patients accordingly 3, 4

5. Partner treatment is NOT routinely needed unless the male partner has symptomatic balanitis (erythematous glans with pruritus) 3

When to Reconsider the Diagnosis

If treatment fails or symptoms recur rapidly, reassess for:

• Bacterial vaginosis (pH >4.5, fishy odor, thin gray discharge)
• Trichomoniasis (pH >4.5, yellow-green frothy discharge, motile trichomonads on wet mount)
• Cytolytic vaginosis (mimics VVC but caused by excessive lactobacilli; treat with sodium bicarbonate sitz baths) 6
• Non-infectious causes: Atrophic vaginitis, contact dermatitis, desquamative inflammatory vaginitis 7, 8

The most recent evidence emphasizes that molecular diagnostic testing (NAAT) outperforms office microscopy for most clinicians 9, 10, so consider sending samples if diagnosis remains uncertain after initial empiric treatment.