What are the treatment options for vaginal pruritus?

Treatment of Vaginal Pruritus

For uncomplicated vaginal pruritus caused by vulvovaginal candidiasis (the most common cause), use either a single 150 mg oral dose of fluconazole or a short-course topical azole such as clotrimazole 1% cream 5g intravaginally for 3 days. 1, 2

Confirm the Diagnosis First

Before treating, establish that this is vulvovaginal candidiasis (VVC):

• Check vaginal pH ≤4.5 – this distinguishes VVC from bacterial vaginosis (pH >4.5) or trichomoniasis (pH >4.5) 2, 3
• Look for white, thick "cottage cheese-like" discharge with vulvovaginal erythema and pruritus – though discharge may be minimal 2, 4
• Perform wet mount with 10% KOH to visualize yeasts or pseudohyphae – this confirms the diagnosis, though empiric treatment is appropriate when clinical presentation is typical 1, 2
• Do NOT treat asymptomatic colonization – 10-20% of women harbor Candida without symptoms 1, 2

First-Line Treatment Options for Uncomplicated VVC

Choose ONE of the following regimens (all achieve 80-90% cure rates):

Oral Therapy (Most Convenient)

• Fluconazole 150 mg oral tablet as a single dose 1, 2

Topical Azole Therapy (Equally Effective)

• Clotrimazole 1% cream 5g intravaginally for 3 days 2
• Clotrimazole 100 mg vaginal tablet for 7 days 1, 5
• Clotrimazole 500 mg vaginal tablet as single dose 1, 5
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1
• Terconazole 0.8% cream 5g intravaginally for 3 days 1

Note: Many topical preparations (clotrimazole, miconazole, butoconazole, tioconazole) are available over-the-counter 1, 6

When to Use Longer Treatment Duration

For severe or complicated VVC, extend treatment to 7-14 days:

• Use clotrimazole 1% cream 5g intravaginally for 7-14 days 2, 5
• OR fluconazole 150 mg every 72 hours for 2-3 doses 1

Complicated VVC includes: severe symptoms, recurrent disease (≥4 episodes/year), non-albicans species (especially C. glabrata), or infection in abnormal hosts (uncontrolled diabetes, immunosuppression) 1

Special Situations

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

• Initial induction: 10-14 days of topical azole or oral fluconazole 1
• Maintenance: Fluconazole 150 mg weekly for 6 months 1
• Obtain vaginal cultures to identify non-albicans species (found in 10-20% of recurrent cases) 1

C. glabrata Infection (Azole-Resistant)

When oral azoles fail:

• Boric acid 600 mg intravaginal gelatin capsule daily for 14 days 1
• OR nystatin 100,000-unit intravaginal suppository daily for 14 days 1
• OR topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

Pregnancy

• Use only topical azoles – oral fluconazole is not recommended during pregnancy 3

Critical Differential Diagnoses to Exclude

Bacterial Vaginosis

• Malodorous "fishy" discharge, pH >4.5, clue cells on wet mount 2, 3
• Treat with metronidazole 500 mg twice daily for 7 days or 2g single dose 2, 3

Trichomoniasis

• Yellow-green frothy discharge, pH >4.5, motile trichomonads on wet mount 2, 5, 4
• Treat with metronidazole 2g single dose or 500 mg twice daily for 7 days 2, 5
• Partner treatment is mandatory 5

Lichen Sclerosus or Vulvar Dermatoses

• Consider in refractory cases with persistent pruritus despite antifungal treatment 7
• May require high-potency topical corticosteroids 7

Common Pitfalls to Avoid

• Do NOT use single-dose regimens for severe symptoms – reserve these for mild-to-moderate uncomplicated cases 1, 2
• Partner treatment is generally unnecessary for VVC – it is not primarily sexually transmitted, though may be considered in recurrent cases 1, 2
• Oil-based creams and suppositories weaken latex condoms and diaphragms 1
• Follow-up is only needed if symptoms persist or recur within 2 months – routine test-of-cure is unnecessary 1, 2
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who have recurrent identical symptoms 1