What over-the-counter (OTC) treatments can be recommended for a 73-year-old female (73F) with vaginal itching, who has a negative vaginitis panel and did not respond to oral Diflucan (fluconazole)?

OTC Recommendations for Vaginal Itching in a 73-Year-Old Female

For a 73-year-old female with vaginal itching who has a negative vaginitis panel and did not respond to oral fluconazole, I recommend trying a topical 1% hydrocortisone cream as first-line OTC treatment to address potential non-infectious inflammatory causes. 1

Understanding the Clinical Scenario

When a patient presents with vaginal itching that has:

• Negative vaginitis panel (ruling out common infectious causes)
• Failed treatment with oral fluconazole (suggesting non-candidal etiology)
• Advanced age (73 years)

This clinical picture strongly suggests a non-infectious cause of vulvovaginal symptoms, particularly given the patient's age.

Recommended OTC Treatment Approach

First-line:

• Topical 1% hydrocortisone cream applied to the external vulvar area twice daily for 7-14 days 1
  • Helps reduce inflammation and itching
  • Available OTC
  • Addresses potential inflammatory or irritant dermatitis

Alternative OTC options if hydrocortisone is ineffective:

• Moisturizing vaginal lubricants or moisturizers (e.g., Replens, K-Y)
  • Addresses potential atrophic vaginitis common in postmenopausal women 2
  • Apply every 2-3 days as needed

Important Considerations

Likely Differential Diagnosis

Given the negative vaginitis panel and fluconazole failure, consider:

1. Genitourinary syndrome of menopause/atrophic vaginitis

   • Common in this age group
   • Presents with vaginal dryness, irritation, and itching 3

2. Contact or irritant dermatitis

   • From soaps, detergents, or hygiene products
   • Responds well to topical hydrocortisone 2

3. Non-albicans Candida species

   • May not respond to fluconazole
   • However, would typically be detected on vaginitis panel 2

Cautions and Follow-up

• Advise the patient to:
  • Avoid potential irritants (perfumed soaps, douches)
  • Wear cotton underwear
  • Use mild, fragrance-free cleansers
  • Return for medical evaluation if symptoms persist after 2 weeks of OTC treatment 4, 2

When to Seek Further Medical Care

The patient should return for further evaluation if:

• Symptoms persist despite 2 weeks of OTC treatment
• New symptoms develop (discharge, odor, bleeding)
• Pain becomes severe or interferes with daily activities 2

If symptoms persist, prescription options that may be considered include:

• Topical estrogen therapy (for atrophic vaginitis)
• Extended-course antifungals or alternative antifungals if non-albicans Candida is suspected
• Evaluation for other dermatologic conditions 3

Remember that unnecessary or inappropriate use of OTC antifungal preparations can delay proper diagnosis and treatment of other vulvovaginal conditions 4, 2.