What medication can be given to a female patient with vaginal itching, suspected to be caused by a yeast infection or other conditions such as bacterial vaginosis or allergic reactions?

Treatment for Vaginal Itching in Females

For vaginal itching suspected to be from a yeast infection, give either a single oral dose of fluconazole 150 mg or short-course topical azole therapy (1-3 days) as first-line treatment. 1

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg as a single oral dose is highly effective and improves compliance, with the CDC recommending this as a first-line option 1, 2
• This is the preferred choice for most patients due to convenience and equivalent efficacy to topical agents 3

Topical Azole Therapy (Equally Effective Alternatives)

• Clotrimazole 500 mg vaginal tablet as a single dose 2
• Clotrimazole 1% cream 5g intravaginally for 7 days (available over-the-counter) 1, 2
• Miconazole 2% cream 5g intravaginally for 7 days 4
• Terconazole 0.4% cream 5g intravaginally for 7 days 4
• Terconazole 0.8% cream 5g intravaginally for 3 days 4

All regimens achieve 80-90% symptom relief and mycological cure rates 2

Diagnostic Confirmation Before Treatment

While empiric treatment is common, proper diagnosis improves outcomes since less than 50% of patients clinically treated for vulvovaginal candidiasis actually have confirmed fungal infection 1:

• **Vaginal pH <4.5** suggests yeast infection (bacterial vaginosis has pH >4.5) 1, 5
• Wet mount showing yeasts or pseudohyphae confirms the diagnosis 1
• Look for characteristic symptoms: vulvovaginal pruritus, erythema, and thick white discharge 1, 3

Critical Caveats and Pitfalls

When NOT to Use Oral Fluconazole

• During pregnancy: use only topical azole therapies 1
• Patients taking quinidine, erythromycin, or pimozide (drug interactions) 3
• Patients with liver problems, kidney problems, or heart arrhythmias require caution 3

Important Warnings for Topical Therapy

• Oil-based creams and suppositories weaken latex condoms and diaphragms 1, 2, 4
• Local burning or irritation may occur but systemic side effects are rare 2

Over-the-Counter Self-Treatment

• Only recommend OTC preparations for women previously diagnosed with vulvovaginal candidiasis who experience identical recurrent symptoms 1, 2
• New or different symptoms require clinical evaluation to rule out misdiagnosis 1

When Treatment Fails

If symptoms persist after 7 days or recur within 2 months 1, 2:

1. Misdiagnosis is the most common reason for treatment failure - consider bacterial vaginosis (pH >4.5, fishy odor, clue cells) or trichomoniasis 1, 5
2. Non-albicans Candida species (particularly C. glabrata) may be less responsive to standard azoles 1
3. Obtain fungal culture or PCR testing to identify resistant species 1
4. Consider longer-duration topical azole therapy (7-14 days) if shorter course was initially used 1

Special Populations

Recurrent Infections (≥4 episodes per year)

• Affects <5% of women and requires evaluation for predisposing conditions: diabetes, immunosuppression, or HIV 1
• Requires longer initial therapy followed by maintenance regimen 1
• Consider treating male partners if they have balanitis (topical antifungal) 1

Contraception Considerations

• Women of childbearing potential should use contraception while taking fluconazole and for 1 week after the final dose 3

Alternative Diagnoses to Consider

If vaginal pH is elevated (>4.5) or symptoms don't match typical yeast infection 5, 6:

• Bacterial vaginosis: thin discharge, fishy odor, clue cells - treat with metronidazole or clindamycin 5, 6
• Trichomoniasis: frothy discharge, strawberry cervix - treat with metronidazole or tinidazole 5
• Atrophic vaginitis: vaginal dryness, dyspareunia in postmenopausal women - treat with estrogen 5
• Allergic/irritant contact vaginitis: identify and remove offending agent 5