Vaginal Yeast Infection: Clinical Presentation and Treatment
Clinical Presentation
Vaginal yeast infection (vulvovaginal candidiasis) classically presents with intense vulvar pruritus, thick white "cottage cheese" discharge, vulvar erythema and edema, and a normal vaginal pH ≤4.5. 1
Key Symptoms
- Vulvar itching is the most characteristic symptom, often the chief complaint 2
- Vaginal discharge that is thick, white, and curd-like 1
- Vaginal soreness, irritation, or burning 1
- External dysuria (burning when urine contacts inflamed vulvar skin) 3
- Dyspareunia (painful intercourse) 1
Physical Examination Findings
- Vulvar edema, erythema, excoriation, or fissures 1
- White, thick vaginal discharge 1
- Normal vaginal pH (≤4.5) distinguishes yeast from bacterial vaginosis or trichomoniasis 1, 3
Critical Diagnostic Confirmation
Before initiating treatment, confirm diagnosis with wet-mount microscopy using 10% potassium hydroxide to visualize budding yeast or pseudohyphae; this test is positive in 50-70% of true cases. 1, 3 If microscopy is negative but clinical suspicion remains high, obtain vaginal culture to identify the Candida species. 1, 3
Treatment of Uncomplicated Vaginal Candidiasis
For uncomplicated vaginal yeast infection, prescribe either a single 150 mg oral dose of fluconazole OR a short-course topical azole regimen (3-7 days); both achieve >90% cure rates. 1, 3
First-Line Oral Option
First-Line Topical Options (Choose One)
3-Day Regimens:
- Miconazole 200 mg vaginal suppository once daily for 3 days 1, 3
- Terconazole 0.8% cream 5g intravaginally once daily for 3 days 1, 3
- Terconazole 80 mg vaginal suppository once daily for 3 days 1, 3
7-Day Regimens:
- Clotrimazole 1% cream 5g intravaginally once daily for 7 days 1, 3
- Miconazole 2% cream 5g intravaginally once daily for 7 days 1, 3
- Terconazole 0.4% cream 5g intravaginally once daily for 7 days 1, 3
Treatment of Complicated/Severe Vaginal Candidiasis
When marked vulvar erythema, edema, excoriation, or fissures are present, avoid single-dose regimens and prescribe extended topical azole therapy for 7-14 days OR fluconazole 150 mg every 72 hours for 3 doses. 1, 3
Extended Topical Regimens for Severe Disease
- Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1, 3
- Miconazole 2% cream 5g intravaginally daily for 7-14 days 1, 3
- Terconazole 0.4% cream 5g intravaginally daily for 7-14 days 1, 3
Alternative Oral Regimen
Treatment of Recurrent Vulvovaginal Candidiasis
Recurrent vulvovaginal candidiasis is defined as ≥4 episodes within 12 months and requires a two-phase treatment approach: induction therapy for 10-14 days followed by maintenance suppression with fluconazole 150 mg weekly for 6 months. 1, 3
Induction Phase (10-14 Days)
Choose one:
- Topical azole therapy daily for 10-14 days (any regimen listed above) 1, 3
- Fluconazole 150 mg orally, repeated after 72 hours 1, 3
Maintenance Phase (6 Months)
- Fluconazole 150 mg orally once weekly for 6 months 1, 3
- This regimen controls symptoms in >90% of patients during treatment 1, 3
- After stopping maintenance therapy, expect a 40-50% recurrence rate 1, 3
Treatment of Non-Albicans Candida Infections
For suspected or confirmed Candida glabrata infection (which accounts for 10-20% of recurrent cases), prescribe boric acid 600 mg intravaginal gelatin capsule once daily for 14 days as first-line therapy. 1, 3
Alternative for C. glabrata
- Extended topical azole therapy for 7-14 days may be tried, but cure rates are substantially lower than for C. albicans 1, 3
- Nystatin is ineffective and should not be used 3
Treatment During Pregnancy
Pregnant women should receive ONLY topical azole therapy for 7 days; oral fluconazole is strictly contraindicated throughout pregnancy due to associations with spontaneous abortion and congenital malformations. 5
Recommended Regimens for Pregnancy
- Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 5
- Miconazole 2% cream 5g intravaginally daily for 7 days 5
- Clotrimazole 100 mg vaginal tablet once daily for 7 days 5
Critical Contraindications in Pregnancy
- Oral fluconazole at any dose is contraindicated 5
- Boric acid is contraindicated during pregnancy 5
- Seven-day courses are significantly more effective than shorter regimens in pregnant women, achieving 80-90% cure rates 5
Critical Pitfalls to Avoid
Do not treat asymptomatic Candida colonization; 10-20% of women harbor Candida without infection, and treatment is not indicated. 1, 3
- Do not prescribe treatment based on symptoms alone without microscopic confirmation; clinical presentation overlaps significantly with bacterial vaginosis and trichomoniasis 1, 3
- Do not recommend over-the-counter self-medication unless the patient has a prior confirmed diagnosis and experiences identical recurrent symptoms 3, 2
- Do not use single-dose regimens for severe vulvar inflammation; these cases require 7-14 day therapy 1, 3
- Do not routinely treat sexual partners; vulvovaginal candidiasis is not sexually transmitted, and partner treatment does not reduce recurrence rates 1, 3
- Do not prescribe nystatin; topical azoles are more effective 3, 6
When to Obtain Cultures
Obtain vaginal cultures when microscopy is negative but clinical suspicion remains high, when symptoms persist after appropriate therapy, or when a patient experiences ≥4 episodes per year to identify non-albicans species. 1, 3
- Culture enables species identification, which is critical because C. glabrata and other non-albicans species show reduced susceptibility to standard azoles 1, 3
- Repeated treatment failures merit antifungal susceptibility testing 3
Special Populations
HIV-Infected Patients
Treatment regimens and expected clinical response are identical for HIV-positive and HIV-negative women; therapy does not need to be altered based on HIV status alone. 1, 3
Diabetic Patients
Uncontrolled diabetes is a predisposing factor for recurrent infections and automatically classifies the case as complicated, requiring extended therapy 1, 2