What are the symptoms and treatment options for a yeast infection?

Symptoms and Treatment of Yeast Infections

Clinical Presentation

Vaginal yeast infections typically present with vulvovaginal itching and erythema, often accompanied by a thick white discharge resembling cottage cheese, though these symptoms are not specific for yeast infection. 1

Key Symptoms

• Vaginal itching is the hallmark symptom of vulvovaginal candidiasis (VVC) 1, 2
• Thick white vaginal discharge that may appear lumpy like cottage cheese 2, 3
• Vaginal soreness, irritation, or burning 2
• Rash or redness on the vulvar skin (external genital area) 2
• Burning sensation during urination 2, 3
• Painful vaginal intercourse 2
• Normal vaginal pH (<4.5) distinguishes yeast infection from other causes of vaginitis 1, 4

Critical Red Flags (NOT Yeast Infection)

• Fever, chills, lower abdominal/back/shoulder pain, or foul-smelling discharge suggest sexually transmitted disease (STD), pelvic inflammatory disease (PID), or tubal pregnancy—seek immediate medical attention 2
• Watery discharge and amine odor are good predictors of an alternative diagnosis like bacterial vaginosis 5

Diagnostic Approach

Diagnosis requires both clinical symptoms AND laboratory confirmation showing yeasts or pseudohyphae on wet preparation with 10% KOH, or positive culture for yeast species. 1, 6

• 10% KOH wet preparation improves visualization of yeast and mycelia by disrupting cellular material 1
• Gram stain showing yeast is the most accurate laboratory method for diagnosis 5
• Culture may be required when microscopy is negative but symptoms persist 7
• Do NOT treat asymptomatic colonization—10-20% of women normally harbor Candida without requiring treatment 1, 4

Important Diagnostic Pitfall

• Patient self-diagnosis is relatively unreliable—clinical criteria including pruritus, caseous discharge, and perineal erythema are more common in yeast vaginitis but can occur with other causes 5
• Only use over-the-counter treatments if previously diagnosed by a physician and experiencing identical symptoms 1, 2

Treatment Options

First-Line Treatment for Uncomplicated Cases

For uncomplicated vaginal yeast infections, either a single 150 mg dose of oral fluconazole OR short-course topical azole therapy (1-7 days) provides 80-90% cure rates. 1, 8

Oral Therapy (Most Convenient)

• Fluconazole 150 mg oral tablet as a single dose 1, 3

Topical Intravaginal Therapy (Multiple Equivalent Options)

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 4
• Clotrimazole 100 mg vaginal tablet for 7 days 1, 4
• Clotrimazole 500 mg vaginal tablet as single dose 1
• Miconazole 2% cream 5g intravaginally for 7 days 1, 4
• Miconazole 100 mg vaginal suppository for 7 days 1, 4
• Miconazole 1200 mg vaginal insert as single dose 2
• Terconazole 0.4% cream 5g intravaginally for 7 days 1, 4
• Terconazole 0.8% cream 5g intravaginally for 3 days 1, 8
• Tioconazole 6.5% ointment 5g intravaginally as single dose 1, 8

Special Populations

Pregnancy

• Use only topical azole antifungals during pregnancy—7-day regimens are more effective than shorter courses 4
• Oral fluconazole is NOT recommended during pregnancy 4
• Use birth control while taking fluconazole and for 1 week after final dose if not pregnant 3

Complicated Cases (10-20% of patients)

• Characterized by severe symptoms, recurrent episodes (≥4/year), immunocompromised status, diabetes, pregnancy, or non-albicans species 8
• Extended therapy with topical azole for 7-14 days OR fluconazole 150 mg every 72 hours for 3 doses 8
• Non-albicans species (particularly C. glabrata) may require boric acid 600 mg vaginal capsules for 14 days 8

Treatment Administration Guidelines

For Topical Therapy

• Apply external cream to vulvar area twice daily for up to 7 days if external itching/irritation present 2
• Complete full course even during menstrual period—hormonal changes often trigger infections just before menses 2
• Do NOT use tampons during treatment—they remove medication from the vagina; use deodorant-free pads instead 2
• Wipe off topical cream before breastfeeding if applied shortly before 6

Important Warnings

• Oil-based creams and suppositories may weaken latex condoms and diaphragms 1, 6, 8
• Avoid vaginal intercourse during treatment 2
• Do NOT use douches, spermicides, or other vaginal products during treatment 2
• Fluconazole can cause dizziness and seizures—avoid driving until you know how it affects you 3
• Fluconazole may cause serious liver problems 3

Partner Management

Vaginal yeast infections are NOT sexually transmitted—routine partner treatment is not recommended. 1, 4, 2

• Male partners with symptomatic balanitis (erythema, pruritus on glans penis) may benefit from topical antifungal treatment 1, 4

Follow-Up Care

Return for follow-up ONLY if symptoms persist after completing treatment or recur within 2 months. 1, 6, 8

• Persistent symptoms after over-the-counter treatment require medical evaluation to exclude other diagnoses 1
• Recurrent infections (≥3 in 6 months or ≥4 per year) warrant physician evaluation for underlying conditions like diabetes, HIV, or immunosuppression 2

Prevention Strategies

Lifestyle Modifications

• Wear cotton underwear and loose-fitting clothes to keep genital area cool and dry 2
• Change out of damp clothes or wet bathing suits immediately 2
• Wipe front to back after bowel movements 2
• Avoid unnecessary antibiotic use when possible—discuss with your physician 2

Risk Factors to Address

• Hormonal changes (few days before menstrual period) 2
• Antibiotic use, birth control pills, steroids 2, 9
• Diabetes, pregnancy, immunosuppression 2, 9
• Tight or moist clothing in genital area 2

Common Pitfalls

• Premature discontinuation of therapy leads to treatment failure—complete the full course even if symptoms improve 6
• Mixed infections with bacterial vaginosis occur in 34% of recurrent cases—failure to recognize this leads to inappropriate empirical therapy 10
• Self-diagnosis without confirmation leads to overuse of antifungals and potential contact dermatitis 8
• Unnecessary treatment of asymptomatic colonization should be avoided 1, 4