How to manage vulvovaginal candidiasis with whitish discharge, vulvar pain, and itching?

Management of Vulvovaginal Candidiasis

For a 23-year-old with whitish discharge, vulvar pain, itching, erythema, edema, and confirmed filamentous hyphae on microscopy with normal vaginal pH, treat with either topical azole therapy or a single dose of oral fluconazole 150 mg. 1, 2

Diagnosis Confirmation

The clinical presentation strongly indicates vulvovaginal candidiasis (VVC) based on:

• Classic symptoms: vulvar pain, itching, whitish discharge
• Physical findings: erythema and edema of vulva, thick whitish discharge
• Diagnostic findings: normal vaginal pH (≤4.5) and filamentous hyphae on microscopy

These findings are consistent with uncomplicated VVC, which is typically caused by Candida albicans 1, 2.

Treatment Options

First-line treatments (equally effective):

1. Topical azole options 1, 2:

   • Clotrimazole 1% cream 5g intravaginally for 7-14 days
   • Clotrimazole 100mg vaginal tablet for 7 days
   • Clotrimazole 100mg vaginal tablet, two tablets for 3 days
   • Clotrimazole 500mg vaginal tablet, single application
   • Miconazole 2% cream 5g intravaginally for 7 days
   • Miconazole 100mg vaginal suppository for 7 days
   • Miconazole 200mg vaginal suppository for 3 days
   • Butoconazole 2% cream 5g intravaginally for 3 days
   • Terconazole 0.4% cream 5g intravaginally for 7 days
   • Terconazole 0.8% cream 5g intravaginally for 3 days
   • Tioconazole 6.5% ointment 5g intravaginally in a single application

2. Oral option 1, 2, 3:

   • Fluconazole 150mg oral tablet as a single dose

Both treatment approaches have 80-90% cure rates for uncomplicated VVC 1, 2.

Treatment Selection Considerations

• Patient preference: Some patients prefer the convenience of a single oral dose over multiple days of topical application
• Previous experience: Consider what has worked well for the patient in the past
• Pregnancy status: If pregnant, only use topical azoles (oral fluconazole is contraindicated in pregnancy) 1, 2
• Medication interactions: Check for potential drug interactions with fluconazole (particularly with quinidine, erythromycin, or pimozide) 3

Follow-up Recommendations

• Follow-up is generally unnecessary for patients who become asymptomatic after treatment 2
• Patients should return only if symptoms persist or recur within 2 months 2
• If symptoms persist despite treatment, consider:
  • Non-albicans Candida species
  • Azole resistance
  • Incorrect diagnosis
  • Poor adherence to treatment

Patient Education

• Advise the patient that symptoms should improve within 2-3 days of starting treatment
• Complete the full course of medication even if symptoms resolve quickly
• Sexual partners generally do not require treatment for VVC 2
• Avoid potential irritants such as scented products, douches, and tight-fitting synthetic clothing

Management of Recurrent VVC

If the patient experiences recurrent episodes (≥4 episodes in 12 months):

1. Initial intensive therapy: Fluconazole 150mg every 72 hours for three doses
2. Maintenance therapy: Weekly fluconazole 150mg for 6 months 4

This regimen has been shown to keep 90.8% of women with recurrent VVC disease-free at 6 months compared to only 35.9% with placebo 4.

Potential Pitfalls

• Misdiagnosis: Always confirm VVC with microscopy or culture before treatment, as symptoms can overlap with bacterial vaginosis or trichomoniasis
• Self-diagnosis: Discourage repeated self-treatment without proper diagnosis
• Recurrence: Be aware that up to 40-45% of women will experience at least two episodes of VVC in their lifetime 1, 5
• Non-albicans species: Consider this possibility in treatment failures, which may require longer duration of therapy 6