What is the diagnosis and recommended treatment for a woman presenting with vulvovaginal candidiasis, including considerations for pregnancy, recurrence, and partner management?

Vulvovaginal Candidiasis: Diagnosis and Treatment

For uncomplicated vulvovaginal candidiasis, treat with either a single 150 mg oral dose of fluconazole or short-course topical azole therapy (1-3 days), both achieving 80-90% cure rates. 1

Diagnosis

Confirm the diagnosis before treating - clinical symptoms alone are insufficient, as less than half of women treated for VVC actually have the infection. 1

• Clinical presentation: Vaginal itching (most specific symptom), vaginal soreness, vulvar burning, dyspareunia, external dysuria, and thick white discharge 1
• Physical findings: Vulvar edema, erythema, excoriation, and white curdlike vaginal discharge 1
• Diagnostic testing: Perform wet mount with 10% KOH to visualize yeast/pseudohyphae AND confirm normal vaginal pH (<4.5) 1
• Culture when needed: Obtain vaginal culture if microscopy is negative but symptoms persist, or in cases of recurrent infection to identify non-albicans species 1

Critical pitfall: Do not treat asymptomatic colonization - 10-20% of women normally harbor Candida without symptoms. 2, 3

Treatment of Uncomplicated VVC

First-Line Options

Oral therapy (preferred for convenience):

• Fluconazole 150 mg single oral dose 1
• Achieves 74.7% therapeutic cure rate at 28 days in clinical trials 4
• Relieves symptoms more rapidly than topical therapy 5

Topical therapy (multiple equivalent options):

• Over-the-counter short-course regimens 1:

  • Miconazole 1200 mg vaginal suppository (single dose)
  • Clotrimazole 500 mg vaginal tablet (single dose)
  • Miconazole 200 mg suppository daily for 3 days
  • Clotrimazole 2% cream 5g daily for 3 days

• Prescription options 1:

  • Terconazole 0.8% cream 5g daily for 3 days
  • Terconazole 80 mg suppository daily for 3 days

Important caveat: Oil-based vaginal creams and suppositories weaken latex condoms and diaphragms. 2, 3

Treatment of Complicated VVC

Complicated VVC includes: Severe symptoms, recurrent episodes (≥4 per year), non-albicans species, pregnancy, uncontrolled diabetes, or immunosuppression. 1

Severe Acute VVC

• Fluconazole 150 mg repeated after 72 hours (2-3 total doses) 1, 2
• OR extended topical azole therapy for 7-14 days 1, 2

Recurrent VVC (≥4 episodes/year)

Affects <5% of women but causes significant morbidity. 2, 6

Two-phase approach 1, 2:

1. Induction therapy (10-14 days):

   • Topical azole for 7-14 days OR
   • Fluconazole 150 mg on days 1,4, and 7

2. Maintenance therapy (6 months):

   • Fluconazole 150 mg weekly for 6 months 1, 2, 7
   • Achieves 90.8% disease-free rate at 6 months vs 35.9% with placebo 7
   • Alternative: Clotrimazole 500 mg vaginal suppository weekly 2

Critical reality check: After stopping maintenance therapy, 30-40% of women experience recurrence within months. 2, 8 Set realistic expectations with patients.

Essential step: Obtain vaginal culture in all recurrent cases to identify non-albicans species, which require different treatment. 2, 8

Non-Albicans VVC (especially C. glabrata)

• Use 7-14 days of non-fluconazole azole therapy 1, 2
• Terconazole preferred due to better activity against non-albicans species 2
• If azole-resistant: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days 1
• Alternative: Nystatin 100,000 unit vaginal suppository daily for 14 days 1, 2

Special Populations

Pregnancy

Use ONLY topical azole therapy for 7 days - oral fluconazole is contraindicated. 2, 9

• Longer duration required as pregnancy reduces treatment efficacy 1

HIV/Immunocompromised

• Treat with extended 7-14 day course 2
• Same regimens as HIV-negative women, but longer duration 1

Partner Management

Do NOT routinely treat asymptomatic partners - VVC is not sexually transmitted. 2, 10

Exception: Treat male partners ONLY if symptomatic with candidal balanitis (erythematous glans with pruritus) using topical antifungal agents. 10

Consider partner treatment only in women with recurrent VVC, though evidence supporting this remains weak. 10

Patient Instructions During Treatment

• Continue treatment through menstrual period 3
• Avoid tampons (remove medication), douches (wash out medication), and spermicides (interfere with treatment) 3
• Avoid sexual intercourse during treatment 3
• Apply external cream twice daily only if vulvar symptoms present 3
• Wear cotton underwear and avoid tight, moist clothing 3
• Return only if symptoms persist or recur within 2 months 2

When to Refer or Reconsider Diagnosis

• Symptoms persist after appropriate treatment 2
• Recurrent infections (≥4 per year) 2, 8
• Presence of fever, lower abdominal/back pain, or foul-smelling discharge (suggests alternative diagnosis like PID) 3
• First episode in woman <12 years old 3