What is the most likely diagnosis and first‑line treatment for a reproductive‑age woman with thick white creamy vaginal discharge and mild itching, and how should management differ if she is pregnant?

Vulvovaginal Candidiasis: Diagnosis and Treatment

A reproductive-age woman presenting with thick white creamy vaginal discharge and mild itching most likely has vulvovaginal candidiasis (VVC), and should be treated with topical azole antifungals for 3-7 days in non-pregnant women or 7 days in pregnant women. 1

Most Likely Diagnosis

• Vulvovaginal candidiasis is the most probable diagnosis based on the characteristic presentation of thick white creamy discharge (resembling cottage cheese) combined with pruritus, which is the most specific symptom for VVC 1, 2

• VVC affects 70-75% of women at least once during their lifetime and represents the second most common cause of vaginal infections in the United States 1

• The vaginal pH in VVC is typically normal (≤4.5), which helps distinguish it from bacterial vaginosis or trichomoniasis where pH is elevated 3, 2

Diagnostic Confirmation

• Diagnosis should be confirmed through clinical symptoms plus microscopic examination using 10% potassium hydroxide (KOH) preparation to visualize yeast forms or pseudohyphae 2, 4

• Yeast culture remains the gold standard when microscopy is negative but clinical suspicion remains high, or in cases of treatment failure 1

• Approximately 50-70% of cases will show hyphae or budding yeast on microscopy, meaning culture may be necessary in microscopy-negative symptomatic patients 5

First-Line Treatment for Non-Pregnant Women

For uncomplicated VVC in non-pregnant women, azole antifungals are the treatment of choice with 80-90% cure rates: 1

Topical Azole Options (Over-the-Counter):

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1
• Clotrimazole 2% cream 5g intravaginally daily for 3 days 1
• Miconazole 2% cream 5g intravaginally daily for 7 days 1
• Miconazole 100mg vaginal suppository daily for 7 days 1

Oral Option:

• Fluconazole 150mg as a single oral dose achieves 55% therapeutic cure rate and offers convenient single-dose therapy 2, 6

Critical Management Differences in Pregnancy

Pregnant women require fundamentally different treatment—only 7-day topical azole therapy is safe and effective: 3

• Oral fluconazole is contraindicated during pregnancy due to associations with spontaneous abortion, craniofacial defects, and heart defects 1, 3

• The CDC explicitly states that pregnant patients must be treated with topical azole antifungals applied intravaginally for 7 days as the sole effective therapy 3

• Seven-day regimens are more effective than shorter courses in pregnancy 3

Recommended Topical Regimens for Pregnancy:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
• Clotrimazole 100mg vaginal tablet daily for 7 days 3
• Miconazole 2% cream 5g intravaginally for 7 days 3
• Miconazole 100mg vaginal suppository daily for 7 days 3
• Terconazole 0.4% cream 5g intravaginally for 7 days 3

Partner Management

• Treatment of sexual partners is not recommended as VVC is not typically sexually transmitted 3, 2

• Partners with symptomatic balanitis may benefit from topical antifungal treatment 3

• Partner treatment has not been shown to reduce recurrence rates in women 2

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization—approximately 10-20% of women normally harbor Candida in the vagina without requiring treatment 3, 2

• Avoid self-medication recommendations except in women previously diagnosed with VVC experiencing identical recurrent symptoms 2

• Never prescribe oral fluconazole during pregnancy—this is a critical safety issue with documented teratogenic risks 1, 3

• Do not rely solely on clinical diagnosis without considering pH testing and microscopy, as less than 50% of women with genital pruritus actually have VVC 7

• Nystatin should be avoided as first-line therapy due to significantly lower efficacy compared to topical azoles 3

When to Reassess

• Patients with persistent or recurrent symptoms should return for follow-up to rule out resistant infection, non-albicans species (particularly Candida glabrata), or alternative diagnoses 3, 2

• If symptoms do not improve within 3 days or persist beyond 7 days, the case should be reclassified as complicated VVC requiring extended therapy (7-14 days of topical azoles or fluconazole 150mg repeated after 3 days in non-pregnant women) 2, 8

• Consider host factors such as uncontrolled diabetes, immunosuppression, or HIV infection, which automatically classify the case as complicated 2