Management of Itchy Vulva in Adult Women
For an adult woman presenting with vulvar itching, first determine if vulvovaginal candidiasis (VVC) is present—characterized by pruritus, vulvovaginal erythema, white discharge, and normal pH (≤4.5)—and if confirmed, treat with either fluconazole 150 mg oral single dose or topical azole therapy such as clotrimazole 1% cream 5g intravaginally for 7-14 days. 1, 2
Diagnostic Algorithm
The initial approach requires identifying the specific cause through targeted assessment:
- Check vaginal pH: Normal pH ≤4.5 suggests VVC, while pH >4.5 indicates bacterial vaginosis or trichomoniasis 1, 2
- Examine discharge characteristics: White discharge with normal pH indicates VVC; yellow-green malodorous discharge suggests trichomoniasis; fishy-smelling discharge (especially after KOH application) indicates bacterial vaginosis 1, 2
- Perform microscopy: Visualize yeasts/pseudohyphae on wet mount or KOH prep for VVC; look for clue cells in bacterial vaginosis 2
- Obtain vaginal cultures if symptoms persist or recur, particularly to identify non-albicans Candida species 1
Important caveat: Self-diagnosis as "thrush" is common and leads to inappropriate over-the-counter antifungal use, causing further irritation. 3 Only women previously diagnosed with VVC who experience identical recurrent symptoms should self-treat; anyone with persistent symptoms after OTC preparations or recurrence within 2 months must seek medical evaluation. 1
Treatment Based on Diagnosis
For Vulvovaginal Candidiasis (Most Common Infectious Cause)
First-line options (both achieve 80-90% cure rates):
- Oral therapy: Fluconazole 150 mg single dose 1, 2
- Topical therapy: Clotrimazole 1% cream 5g intravaginally for 7-14 days, miconazole 2% cream 5g intravaginally for 7 days, or terconazole 0.8% cream 5g intravaginally for 3 days 1, 2
The CDC 2021 guidelines establish azole antifungals as the treatment of choice for uncomplicated VVC. 4 Short-course topical therapy (1-3 days) is equally effective as longer courses for uncomplicated cases. 2
For Trichomoniasis
For Bacterial Vaginosis
- Oral metronidazole or clindamycin with follow-up evaluation one month after treatment completion 1
For Non-Infectious Causes
If infectious causes are excluded and inflammatory dermatoses suspected:
- Topical corticosteroids may be appropriate for conditions like lichen sclerosus or contact dermatitis 5, 6
- Hydrocortisone cream can be applied to affected areas not more than 3-4 times daily for external genital itching in adults 7
Special Population Considerations
Pregnancy
Critical warning: Pregnant women should receive only 7-day topical azole therapies; oral fluconazole is contraindicated as it may be associated with spontaneous abortion, craniofacial defects, and heart defects. 4, 1, 2
HIV-Positive Women
- Treatment for VVC does not differ from HIV-negative women 4, 1
- Lower CD4+ T-cell counts correlate with increased VVC rates 4, 1
- VVC is associated with increased viral shedding 4
Recurrent VVC (≥4 Episodes/Year)
- Requires longer initial therapy followed by 6-month maintenance regimen with clotrimazole or fluconazole 2
- Evaluate for predisposing conditions: diabetes, immunosuppression, HIV, antibiotic use 2
- Consider oteseconazole (not yet commercially available) as a new option 4
Non-Albicans Candida Infections
- Boric acid appears useful for symptomatic non-albicans yeast infections 4
- Obtain cultures to identify unusual species when symptoms persist 1
What NOT to Use
No evidence supports:
- Probiotics for VVC treatment 4
- Crotamiton cream for generalized pruritus 4
- Topical capsaicin or calamine lotion 4