What are the diagnoses and treatments for a 20‑year‑old woman with severe vulvovaginal candidiasis (thrush) and a genital human papillomavirus (HPV) lesion (condyloma)?

Dual Diagnosis: Severe Vulvovaginal Candidiasis and Genital HPV Condyloma

This 20-year-old woman has two distinct conditions requiring simultaneous but separate treatment: severe vulvovaginal candidiasis (complicated VVC) and genital HPV condyloma (genital warts), and the presence of both infections at this young age warrants HIV testing and evaluation for immunosuppression. 1, 2

Critical Initial Assessment

The combination of severe thrush and HPV lesions in a young woman raises concern for underlying immunocompromise:

• Screen immediately for HIV infection, diabetes mellitus, and other immunosuppressive conditions because the presence of both severe candidiasis and visible HPV lesions suggests impaired cell-mediated immunity 1, 2
• Obtain vaginal pH testing and wet-mount microscopy with 10% KOH preparation to confirm candidiasis by visualizing yeast forms or pseudohyphae, and measure pH (should be ≤4.5 for VVC) 1, 2
• Perform vaginal culture for Candida species identification because severe or recurrent cases may involve non-albicans species like C. glabrata that require different treatment approaches 1

Treatment of Severe Vulvovaginal Candidiasis

For severe (complicated) VVC, prescribe extended-duration topical azole therapy for 7-14 days OR fluconazole 150 mg orally every 72 hours for 3 doses (days 1,4, and 7). 1, 2, 3

Specific Topical Regimen Options:

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1, 2
• Miconazole 2% cream 5g intravaginally daily for 7-14 days 1, 2
• Terconazole 0.4% cream 5g intravaginally daily for 7-14 days 1, 4

If Non-albicans Species Identified:

• For C. glabrata infection, use boric acid 600 mg vaginal suppositories daily for 14 days (must be compounded by pharmacist) 1, 3
• C. glabrata shows reduced azole susceptibility and requires alternative therapy 1, 2

Maintenance Therapy Consideration:

• If this represents recurrent VVC (≥3 episodes in 12 months), initiate maintenance suppressive therapy with fluconazole 150 mg weekly for 6 months after achieving initial cure 1, 2

Treatment of Genital HPV Condyloma

For external genital warts, offer patient-applied imiquimod 5% cream OR provider-administered cryotherapy with liquid nitrogen as first-line options. 1

Patient-Applied Options:

• Imiquimod 5% cream applied once daily at bedtime, 3 times per week for up to 16 weeks (wash off after 6-10 hours) 1
• Podofilox 0.5% solution or gel applied twice daily for 3 days, followed by 4 days off therapy, repeated for up to 4 cycles 1

Provider-Administered Options:

• Cryotherapy with liquid nitrogen applied every 1-2 weeks until lesions resolve 1
• Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90% applied directly to warts weekly until cleared 1
• Surgical removal via excision, electrocautery, or laser ablation for large or refractory lesions 1

Critical Management Considerations

HIV and Immunosuppression:

• HIV-infected women should receive identical treatment regimens for both VVC and HPV lesions as HIV-negative women, though response rates may be lower and recurrence rates higher 1, 2
• Immunosuppressed patients with condyloma often harbor multiple HPV types including high-risk oncogenic types (HPV 16,18) and may develop dysplasia 5

Partner Management:

• Routine treatment of sexual partners is NOT recommended for VVC because it does not reduce recurrence rates 1, 2
• Treat the partner only if he has symptomatic balanitis (penile erythema, pruritus) with topical antifungal 1, 2
• Sexual partners of patients with genital warts do NOT require treatment unless they have visible warts themselves 1
• Counsel that HPV transmission likely occurred before wart appearance, and most sexually active adults acquire HPV at some point 1

Pregnancy Considerations:

• If this patient is or becomes pregnant, use ONLY 7-day topical azole therapy for candidiasis (never oral fluconazole in first trimester) 1, 2, 3
• Cryotherapy or TCA/BCA are safe options for genital warts during pregnancy; avoid podophyllin and podofilox 1

Common Pitfalls to Avoid

• Do not treat with single-dose or short-course (1-3 day) antifungal regimens for severe VVC as these are only appropriate for uncomplicated mild-moderate disease 1
• Do not use podophyllin on vaginal, cervical, or urethral warts due to risk of perforation and fistula formation 1
• Do not assume VVC is the only vaginal infection present; severe candidiasis can coexist with bacterial vaginosis or trichomoniasis requiring concurrent treatment 2
• Do not delay HIV testing in young patients presenting with multiple opportunistic infections 1, 2
• Do not biopsy typical-appearing condyloma unless lesions are atypical, pigmented, indurated, fixed, ulcerated, or unresponsive to therapy 6, 7

Follow-Up Protocol

• Instruct the patient to return if candidiasis symptoms persist after completing the 7-14 day treatment course or recur within 2 months 2, 3
• Schedule follow-up for wart assessment 2-4 weeks after initiating therapy to evaluate response and continue treatment as needed 1
• Ensure HIV test results are reviewed and appropriate counseling provided 1, 2
• Recommend HPV vaccination if not previously completed (effective against HPV types 6,11,16,18) 1