From the Guidelines
For a patient with itching, thick white discharge, and negative tests for yeast and bacterial vaginosis (BV), I recommend empiric treatment with clotrimazole 1% cream or miconazole 2% cream applied intravaginally daily for 7 days, or fluconazole 150mg oral single dose, as the most recent and highest quality study suggests that clinical diagnosis and microscopy may have poor sensitivity and specificity for vulvovaginal candidiasis (VVC) diagnosis 1. Despite negative swab results, false negatives can occur with yeast infections, particularly if microscopy alone was used. The 2021 Centers for Disease Control and Prevention of Sexually Transmitted Infections treatment guidelines recommend various treatment regimens for VVC, including over-the-counter intravaginal agents and prescription intravaginal agents 1. Some key points to consider in the treatment of VVC include:
- The use of azole antifungals, such as clotrimazole and miconazole, as the primary treatment for VVC 1
- The importance of considering alternative diagnoses, such as cytolytic vaginosis, allergic or contact dermatitis, trichomoniasis, desquamative inflammatory vaginitis, or lichen simplex chronicus, if symptoms persist after treatment 1
- The need for patients to avoid scratching, wear cotton underwear, and avoid tight clothing during treatment to prevent symptom exacerbation
- The potential for molecular testing, such as polymerase chain reaction (PCR), to improve the diagnosis of VVC, with high clinical accuracy and sensitivity 1
From the Research
Symptoms and Diagnosis
- The symptoms described, including itching without dysuria, a thick white discharge, and negative yeast and bacterial vaginosis (BV) swab results, are consistent with vulvovaginal candidiasis 2, 3, 4, 5.
- Vulvovaginal candidiasis typically presents with a thick, "curdled" white discharge, vulvar pruritus, and a hyperemic vagina 2.
- The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy or DNA probe testing 4, 5.
Treatment Options
- Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy 4.
- For uncomplicated vulvovaginal candidiasis, topical azole and oral fluconazole are equally efficacious 5.
- Recurrent infections may be treated with fluconazole 150mg weekly for up to 12 consecutive weeks 2.
Differential Diagnosis
- Bacterial vaginosis (BV) and trichomoniasis are other common causes of vaginitis, but the symptoms and negative swab results suggest that these are not the primary cause in this case 2, 3, 4, 6.
- Atrophic vaginitis, irritant, allergic, and inflammatory vaginitis are less common and may also present with similar symptoms, but the thick white discharge is more characteristic of vulvovaginal candidiasis 4, 6.