What is the appropriate diagnosis and treatment approach for a patient presenting with vaginal pruritus?

Vaginal Pruritus: Diagnosis and Treatment

Initial Diagnostic Approach

The most common cause of vaginal pruritus is vulvovaginal candidiasis, followed by chronic dermatoses such as lichen sclerosus and vulvar eczema, requiring microscopic confirmation before treatment. 1

Essential Diagnostic Steps

• Obtain microscopic confirmation using wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae before initiating any treatment 2, 3
• Check vaginal pH: Normal pH (≤4.5) suggests candidiasis, while pH >4.5 indicates bacterial vaginosis or trichomoniasis 2, 4
• Examine for specific findings: White discharge with vulvar erythema suggests candidiasis; porcelain-white plaques with fissures indicate lichen sclerosus; milky discharge with fishy odor suggests bacterial vaginosis 2, 5, 4
• Do not treat asymptomatic colonization, as 10-20% of women harbor Candida species without infection 2, 3

Critical Differential Diagnoses

The causes vary by presentation pattern:

• Pruritus with white discharge and normal pH: Vulvovaginal candidiasis (most common) 2, 1
• Pruritus with fissuring, bleeding, and dyspareunia in postmenopausal women: Lichen sclerosus 5
• Pruritus with milky discharge, pH >4.5, and fishy odor: Bacterial vaginosis 4
• Pruritus with frothy discharge and pH >5.4: Trichomoniasis 4

Treatment Algorithm for Confirmed Vulvovaginal Candidiasis

Uncomplicated VVC (90% of cases)

For uncomplicated vulvovaginal candidiasis, use either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-7 days), both achieving >90% response rates. 3

First-line options (choose one):

• Oral: Fluconazole 150 mg as single dose 2, 3
• Topical: Clotrimazole 1% cream 5g intravaginally for 7-14 days 2, 3
• Topical: Miconazole 2% cream 5g intravaginally for 7 days 2, 3
• Topical: Terconazole 0.4% cream 5g intravaginally for 7 days 2

Complicated VVC (10% of cases)

Complicated VVC includes: severe symptoms, recurrent episodes (≥4/year), non-albicans species, pregnancy, diabetes, or immunosuppression 3

Treatment approach:

• Use extended therapy: Topical azoles for 7-14 days OR fluconazole 150 mg every 72 hours for 2-3 doses 3
• Avoid single-dose treatments in complicated cases 3

Recurrent VVC (≥4 episodes/year)

For recurrent vulvovaginal candidiasis, use a two-phase approach: induction therapy with 10-14 days of topical azole or oral fluconazole, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months. 3

• Induction phase: 10-14 days of topical azole OR oral fluconazole 3
• Maintenance phase: Fluconazole 150 mg orally weekly for 6 months (achieves control in >90% of patients) 3
• Expect 40-50% recurrence rate after cessation of maintenance therapy 3

Special Population Considerations

Pregnancy

• Avoid oral fluconazole due to association with spontaneous abortion and congenital malformations 3
• Use only topical azole therapy for 7 days 3

HIV-Positive Patients

• Treatment regimens are identical to HIV-negative women with equivalent response rates 2, 3

Elderly Patients

• Start with emollients and topical steroids for at least 2 weeks to treat asteatotic eczema 2
• Avoid sedating antihistamines in elderly patients 2
• Consider gabapentin if initial treatment fails 2

Prepubertal Children

• VVC in a 3-year-old represents complicated disease requiring investigation for predisposing factors 6
• Use topical azole therapy for 7-14 days rather than single-dose treatments 6
• Avoid oral fluconazole unless absolutely necessary 6

Over-the-Counter Self-Treatment

• Self-medication should only be advised for women previously diagnosed with VVC who experience recurrence of identical symptoms 2, 3
• Seek medical care if symptoms persist after OTC treatment or recur within 2 months 2, 3
• Available OTC preparations: Clotrimazole, miconazole, butoconazole, and tioconazole 2
• OTC products are for ages 12 and older only 7

Critical Pitfalls to Avoid

• Do not assume diagnosis without microscopic confirmation, as self-diagnosis is unreliable 3
• Do not treat asymptomatic colonization found incidentally 2, 3
• Do not use single-dose therapy for severe symptoms or complicated cases 3
• Remember that VVC can occur concomitantly with STDs, requiring appropriate testing 2, 3
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 2
• In refractory cases, consider invasive or preinvasive lesions such as VIN in the differential diagnosis 1

When to Refer

• Refer to secondary care if diagnostic doubt exists or primary care management fails to relieve symptoms 2
• Consider biopsy if diagnosis is uncertain, disease fails to respond to treatment, or neoplastic change is suspected 5
• Follow up regularly when underlying systematic cause is not evident 2