What is the diagnosis and treatment for a woman presenting with white, flothy vaginal discharge, possibly indicating a yeast infection caused by Candida albicans?

White Frothy Discharge in Women: Diagnosis and Treatment

Immediate Diagnostic Clarification

White frothy discharge most commonly indicates vulvovaginal candidiasis (yeast infection), not trichomoniasis—the classic "frothy" discharge of trichomoniasis is typically yellow-green, not white. 1 A white, thick, curd-like discharge with pruritus strongly suggests Candida infection, which affects 75% of women at least once in their lifetime. 1, 2

Diagnostic Approach

Confirm the diagnosis before treatment through:

• Wet-mount preparation with 10% KOH to visualize yeast, pseudohyphae, or budding yeast (present in 50-70% of cases) 1, 3
• Vaginal pH measurement—normal pH (≤4.5) supports candidiasis; elevated pH (>4.5) suggests bacterial vaginosis or trichomoniasis instead 1
• Vaginal culture if microscopy is negative but symptoms persist 1, 4

Critical pitfall: Do not treat based on symptoms alone—self-diagnosis is unreliable, and up to 10-20% of asymptomatic women harbor Candida without infection. 1, 4 Treating colonization without symptoms is inappropriate. 1, 4

First-Line Treatment for Uncomplicated Candidiasis

For uncomplicated vulvovaginal candidiasis (sporadic episodes, mild-to-moderate symptoms, immunocompetent, non-pregnant women), use either:

Oral Therapy (Preferred for Convenience)

• Fluconazole 150 mg orally as a single dose achieves >90% response rates 1, 4, 5

Topical Therapy (Equally Effective)

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1, 6
• Miconazole 2% cream 5g intravaginally daily for 7 days 1, 4
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 1, 4
• Single-dose options: Tioconazole 6.5% ointment 5g intravaginally once 1, 4

Both oral and topical azoles achieve 80-90% symptom relief and negative cultures. 1 Topical azoles are more effective than nystatin. 1

Treatment for Complicated Candidiasis

For severe symptoms, recurrent disease (≥4 episodes/year), non-albicans species, or immunocompromised patients:

• Fluconazole 150 mg orally every 72 hours for 2-3 doses (total of 3 doses) 1, 4
• OR topical azole therapy for 7-14 days 1, 4, 2

Recurrent Vulvovaginal Candidiasis Management

For women with ≥4 episodes per year, use a two-phase approach: 1, 4, 2

1. Induction phase: 10-14 days of topical azole OR oral fluconazole 1, 4
2. Maintenance phase: Fluconazole 150 mg orally weekly for 6 months achieves control in >90% of patients 1, 4, 2

Important caveat: After stopping maintenance therapy, expect 40-50% recurrence rate. 1 Investigate contributing factors including immunosuppression, diabetes, antibiotic use, and contraceptive methods. 4, 7

Special Population Considerations

Pregnancy

Avoid oral fluconazole in pregnancy due to association with spontaneous abortion and congenital malformations. 4, 5 Use only topical azole therapy for 7 days. 1, 4, 2

HIV-Positive Women

Treatment regimens are identical to HIV-negative women with equivalent response rates expected. 1, 4

Treatment-Resistant Cases

For C. glabrata infections unresponsive to oral azoles:

• Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 1, 4
• OR nystatin 100,000-unit vaginal suppository daily for 14 days 1
• OR topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

C. glabrata shows increasing prevalence and reduced azole susceptibility. 3, 7 Amphotericin B demonstrates highest susceptibility (68.1%) against resistant species. 7

Critical Management Pitfalls

• Do not use single-dose treatments for severe symptoms, recurrent disease, or complicated cases—these require extended therapy 4
• Screen for concurrent sexually transmitted infections, as vulvovaginal candidiasis can coexist with STDs 1, 4
• Women whose symptoms persist after over-the-counter treatment or recur within 2 months require medical evaluation to exclude resistant organisms or alternative diagnoses 4
• Partner treatment is not indicated for candidiasis, unlike trichomoniasis 8, 2

Adverse Effects to Counsel Patients About

Oral fluconazole: Nausea, abdominal pain, headache (13% of patients), diarrhea, and potential drug interactions with warfarin, statins, calcium channel blockers, and protease inhibitors 5

Topical agents: Local burning or irritation, but rarely systemic effects 4 Note that oil-based creams and suppositories may weaken latex condoms and diaphragms 1