What is the likely diagnosis and treatment for a reproductive-aged female with white lesions and surrounding erythema on the labia minora, potentially with a history of vaginal yeast infections?

White Lesions with Surrounding Erythema on Labia Minora

This clinical presentation is most consistent with vulvovaginal candidiasis (VVC), and you should treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy for 3-7 days. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with the following steps:

• Perform a wet-mount preparation using 10% potassium hydroxide (KOH) to visualize yeast or pseudohyphae, which confirms candidal infection. 3, 1, 2
• Check vaginal pH using narrow-range pH paper – VVC characteristically presents with normal pH (≤4.5), distinguishing it from bacterial vaginosis or trichomoniasis. 3, 1, 2
• Obtain fungal cultures if microscopy is negative but clinical suspicion remains high, particularly in women with recurrent symptoms who may harbor non-albicans species or azole-resistant strains. 1, 4

The white lesions with surrounding erythema on the labia minora represent the classic vulvar involvement pattern of VVC, where inflammation extends beyond vaginal mucosa to external genital skin. 1 Erythema of the vulvar skin is a hallmark diagnostic feature, often accompanied by edema and satellite lesions. 1

First-Line Treatment Options

For uncomplicated VVC (sporadic episodes, mild-to-moderate symptoms, immunocompetent non-pregnant women), choose one of the following equally effective regimens:

Oral therapy:

• Fluconazole 150 mg as a single oral dose – achieves >90% response rates and offers superior convenience. 1, 2

Topical therapy options (all achieve 80-90% cure rates): 3, 1

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 3, 2, 5
• Miconazole 2% cream 5g intravaginally daily for 7 days 3, 2
• Terconazole 0.4% cream 5g intravaginally daily for 7 days 3, 2
• Miconazole 200 mg vaginal suppository daily for 3 days 3, 2

Topical azole preparations treat both vaginal and vulvar skin involvement simultaneously, with intravaginal application providing adequate coverage for the external lesions. 1

When to Extend Treatment Duration

For severe vulvar inflammation with extensive erythema and white lesions, use extended topical azole therapy for 7-14 days rather than single-dose treatments. 1, 2 This represents complicated VVC requiring longer initial therapy. 1

If this is a recurrent episode (≥4 episodes per year), implement a two-phase approach: 1, 2

• Induction phase: 10-14 days of topical azole therapy or fluconazole 150 mg every 72 hours for 2-3 doses 1, 2
• Maintenance phase: Fluconazole 150 mg orally weekly for 6 months, which achieves symptom control in >90% of patients 1, 2

Critical Pitfalls to Avoid

• Never treat based solely on clinical appearance without microscopic confirmation, as self-diagnosis is unreliable and leads to misdiagnosis in many cases. 1, 4, 6
• Do not assume this is VVC if vaginal pH is elevated (>4.5) – this suggests bacterial vaginosis or trichomoniasis, which may coexist with candidiasis and require concurrent treatment. 1
• Avoid recommending over-the-counter self-treatment unless the patient has been previously diagnosed with VVC and recognizes identical recurrent symptoms. 3, 1
• Any woman whose symptoms persist after treatment or recur within 2 months must undergo repeat evaluation to rule out resistant organisms, non-albicans species, or alternative diagnoses. 1, 2

Special Population Considerations

For pregnant women: Use only 7-day topical azole therapy and never prescribe oral fluconazole due to associations with spontaneous abortion and congenital malformations. 1, 2

For HIV-infected women: Treatment regimens should be identical to HIV-negative women, with equivalent response rates expected. 1, 2

When to Investigate Further

If the patient has recurrent episodes, investigate contributing factors including: 7

• Uncontrolled diabetes or hyperglycemia 7
• Immunosuppression (HIV, corticosteroid use) 1, 7
• Frequent antibiotic use 1, 7
• Non-albicans Candida species (less responsive to azoles) 2, 4

VVC can occur concomitantly with sexually transmitted diseases, so maintain appropriate clinical suspicion and testing when indicated. 3, 1