What treatment is recommended for a woman complaining of vaginal itching and irritation?

Treatment for Vaginal Itching and Irritation in Hospitalized Women

For inpatient women complaining of vaginal itching and irritation, fluconazole 150 mg as a single oral dose is the recommended first-line treatment for presumed uncomplicated vulvovaginal candidiasis. 1, 2

Diagnostic Approach

Before initiating treatment, confirm the diagnosis with:

• Wet mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae
• pH testing (normal pH <4.5 suggests candidiasis)
• Assessment for other symptoms such as discharge characteristics, vulvar edema, erythema, excoriation, or fissures

Treatment Algorithm

1. First-line Treatment for Uncomplicated Vulvovaginal Candidiasis

• Oral therapy: Fluconazole 150 mg single oral dose 3, 1, 2
• Alternative topical options (if oral therapy is contraindicated):
  • Clotrimazole 1% cream applied intravaginally for 7 days
  • Miconazole 2% cream applied intravaginally for 7 days 1

2. For Complicated Vulvovaginal Candidiasis

• If severe symptoms (extensive vulvar erythema, edema, excoriation, and fissures):

  • Fluconazole 150 mg in two sequential doses (second dose 72 hours after initial dose) 1
  • OR topical azole therapy for 7-14 days 3, 1

• If non-albicans Candida species suspected (particularly C. glabrata):

  • Topical boric acid 600 mg daily intravaginally for 14 days 3

3. For Recurrent Vulvovaginal Candidiasis (≥4 episodes in 12 months)

• 10-14 days of induction therapy with topical or oral azole
• Followed by fluconazole 150 mg once weekly for 6 months 3

4. For Non-Candidal Causes

• If bacterial vaginosis suspected (fishy odor, thin discharge, pH >4.5):

  • Oral metronidazole 500 mg twice daily for 7 days
  • OR clindamycin cream 2% intravaginally for 7 days 1, 4

• If trichomoniasis suspected (yellow-green discharge, irritation):

  • Metronidazole 2g orally as a single dose 4, 5

• If non-infectious causes (irritant vulvovaginitis, allergic reactions):

  • Elimination of potential irritants
  • Use of emollients instead of soaps 1

Special Considerations

• Pregnant patients: Use only topical azole therapies for 7 days; avoid oral fluconazole due to potential risk of spontaneous abortion 1

• Diabetic or immunocompromised patients: May require longer duration of therapy and closer monitoring 1

• Elderly patients: Consider longer treatment duration (7-14 days) due to reduced immune function and slower healing time 1

Common Pitfalls to Avoid

1. Treating without confirming diagnosis: Always perform wet mount and pH testing before initiating therapy, as symptoms of vaginal itching and irritation are nonspecific 3, 1

2. Missing non-infectious causes: Remember that 5-10% of vaginitis cases are non-infectious, including atrophic, irritant, allergic, or inflammatory vaginitis 1, 4

3. Inadequate treatment duration: For complicated cases, single-dose therapy is often insufficient 3, 1

4. Failure to consider multiple causes: Multiple infections or conditions may coexist 1

5. Neglecting prevention strategies: Advise patients on preventive measures including good genital hygiene, wearing cotton underwear, and avoiding irritants 1

Follow-up

Follow-up is recommended if:

• Symptoms persist after 2 weeks of adequate treatment
• Symptoms are severe or worsening
• Patient has underlying medical conditions that may complicate treatment 1