What is the diagnosis and treatment for a 25-year-old female with itching and white, thick vaginal discharge (pv) for a week?

Diagnosis and Treatment of Vulvovaginal Candidiasis

Diagnosis

This presentation of white, thick vaginal discharge with itching for one week is classic for vulvovaginal candidiasis (VVC), and you should treat with either a single 150 mg dose of oral fluconazole or a 7-day course of topical azole therapy. 1

The clinical picture strongly suggests VVC based on:

• Pruritus (itching) as the predominant symptom 1
• White, thick discharge (often described as "curd-like" or "cottage cheese-like") 1, 2
• Duration of one week suggests uncomplicated VVC 1

Confirm the Diagnosis

Before treating, you should confirm VVC by:

• Check vaginal pH - should be ≤4.5 (normal range) 1, 3
• Perform wet mount with 10% KOH - look for yeasts or pseudohyphae 1, 3
• Assess for vulvar erythema and vaginal inflammation 1, 2

The 2009 IDSA guidelines emphasize that diagnosis should be confirmed before empirical treatment, as symptoms are nonspecific 1. However, in a 25-year-old with classic presentation, presumptive treatment is reasonable while awaiting confirmation 4.

First-Line Treatment Options

Option 1: Oral Fluconazole (Preferred for Convenience)

Fluconazole 150 mg as a single oral dose 1, 5

• Achieves >90% response rates in uncomplicated VVC 1
• Equivalent efficacy to 7-day topical azole regimens 1, 5
• Most convenient option for patient compliance 4

Option 2: Topical Azole Therapy

If oral therapy is contraindicated or patient prefers topical treatment, use any of these intravaginal regimens 1:

Short-course (3-day) regimens:

• Clotrimazole 100 mg vaginal tablet, two tablets for 3 days 1
• Miconazole 200 mg vaginal suppository, one daily for 3 days 1
• Terconazole 0.8% cream 5g intravaginally for 3 days 1

Standard (7-day) regimens:

• Clotrimazole 1% cream 5g intravaginally for 7 days 1, 3
• Miconazole 2% cream 5g intravaginally for 7 days 1, 3
• Terconazole 0.4% cream 5g intravaginally for 7 days 1

The 2009 IDSA guidelines state that no topical agent is clearly superior to another 1. Many of these preparations are available over-the-counter 1, 3.

Treatment Selection Algorithm

For this 25-year-old with uncomplicated VVC:

1. If no contraindications exist → Prescribe fluconazole 150 mg single dose 1, 5
2. If pregnant → Use only topical azole for 7 days (fluconazole contraindicated) 6
3. If breastfeeding → Discuss risks/benefits; topical therapy preferred 5
4. If patient prefers topical → Any 3-7 day azole regimen 1

Important Counseling Points

What to Tell the Patient

• Symptoms should improve within 2-3 days and resolve completely by end of treatment 4
• Complete the full course even if symptoms improve early (for topical regimens) 7
• Oil-based topical preparations weaken latex condoms and diaphragms 3, 5
• Sexual partners do NOT need treatment - VVC is not sexually transmitted 1, 3
• Return only if symptoms persist after treatment or recur within 2 months 3

When to Avoid Fluconazole

Do not prescribe oral fluconazole if patient 5:

• Is pregnant or may become pregnant 5
• Takes quinidine, erythromycin, or pimozide 5
• Has known liver problems 5

Common Pitfalls to Avoid

Do NOT treat asymptomatic colonization - 10-20% of women normally harbor Candida without requiring treatment 1, 3. Only treat when symptoms are present.

Do NOT assume all vaginal discharge is yeast - bacterial vaginosis accounts for 40-50% of vaginitis cases versus only 20-25% for candidiasis 4. The thick white discharge and predominant itching (rather than odor) distinguish VVC from bacterial vaginosis 2, 4.

Do NOT use single-dose or short-course therapy for complicated VVC - if patient has severe symptoms, recurrent infections (≥4 episodes/year), diabetes, immunosuppression, or non-albicans Candida, use 7-14 day topical therapy or multiple doses of fluconazole 1.

Follow-Up Management

If symptoms persist after treatment:

• Reconsider the diagnosis 8
• Consider non-albicans Candida species (C. glabrata resistant to azoles) 1, 2
• Culture to identify species and consider boric acid 600 mg intravaginally for 14 days for azole-resistant strains 1

If recurrent VVC develops (≥4 episodes/year):

• Use 10-14 days induction therapy with topical or oral azole 1
• Follow with fluconazole 150 mg once weekly for 6 months as suppressive therapy 1
• Evaluate for predisposing conditions (diabetes, immunosuppression, antibiotic use) 3, 4