Yeast infection of the vulva/vagina — thick white discharge, intense pruritus, normal pH.
Also known as: yeast infection, candidiasis, vulvovaginal candidiasis, VVC, monilial vaginitis
Overview
Symptomatic vulvar and vaginal inflammation caused by Candida species, most commonly Candida albicans (~85-90%), with C. glabrata, C. krusei, and C. tropicalis accounting for non-albicans cases that are often azole-resistant.
Epidemiology
Affects ~75% of women at least once; ~5-8% experience recurrent vulvovaginal candidiasis (RVVC, ≥3 episodes/year). Second most common cause of vaginitis after BV.
Try two board-style Candidal Vulvovaginitis questions
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Question 1ReproductiveEasy
A 32-year-old woman presents with 3 days of vulvar itching, burning, and thick white discharge. She was started on azithromycin 5 days ago for community-acquired pneumonia and takes quetiapine nightly for bipolar disorder. Pelvic exam reveals erythematous vulva with curd-like discharge; KOH prep shows pseudohyphae and budding yeast. ECG from her last admission showed a QTc of 470 ms. Which of the following is the most appropriate treatment?
AIntravaginal metronidazole
BIntravaginal clotrimazole
COral itraconazole
DOral fluconazole
Reveal answer & full explanation
Correct answer: B — Intravaginal clotrimazole
AIntravaginal metronidazole
BIntravaginal clotrimazole✓
COral itraconazole
DOral fluconazole
Why Intravaginal clotrimazole is correct
This patient has uncomplicated vulvovaginal candidiasis: vulvar itching and burning, curd-like discharge, and a KOH prep showing pseudohyphae and budding yeast
The decisive issue is medication-related QT risk — azithromycin and quetiapine both prolong the QT interval, and her baseline QTc is already borderline-prolonged at 470 ms
Intravaginal azoles (clotrimazole, miconazole, terconazole) are highly effective for uncomplicated candidiasis and have negligible systemic absorption, so they avoid additive QT prolongation
For uncomplicated disease, topical and oral azoles are equally effective, so safety is the tie-breaker and the topical agent is the most appropriate choice
Why the others are wrong
Intravaginal metronidazole — treats bacterial vaginosis and trichomoniasis and has no activity against Candida; buzzword-match trap, since 'vaginal discharge' pattern-matches to metronidazole but the KOH pseudohyphae and budding yeast identify yeast, not clue cells or motile trichomonads
Oral itraconazole — an oral azole that also prolongs QT and inhibits CYP3A4, carrying the same additive torsades risk as fluconazole, and it is not first-line for vaginal candidiasis; right-diagnosis-wrong-route trap
Oral fluconazole — the textbook single-dose first-line for uncomplicated candidiasis, but it prolongs QT via hERG blockade and would compound the risk from azithromycin, quetiapine, and the elevated baseline QTc; premature-closure trap
Question 2ReproductiveEasy
A 24-year-old woman who is not pregnant has thick, white, 'cottage cheese' vaginal discharge with vulvar pruritus and burning. There is no malodor. A potassium hydroxide (KOH) prep of the discharge shows pseudohyphae and budding yeast. Which of the following is the most appropriate treatment?
AFluconazole 150 mg weekly for 6 months
BMetronidazole 500 mg BID for 7 days
CBoric acid vaginally for 14 days
DFluconazole 150 mg PO single dose
Reveal answer & full explanation
Correct answer: D — Fluconazole 150 mg PO single dose
AFluconazole 150 mg weekly for 6 months
BMetronidazole 500 mg BID for 7 days
CBoric acid vaginally for 14 days
DFluconazole 150 mg PO single dose✓
Why Fluconazole 150 mg PO single dose is correct
Thick, white, curd-like discharge without odor, intense vulvar pruritus, and a KOH prep showing pseudohyphae and budding yeast identify uncomplicated vulvovaginal candidiasis (Candida albicans).
Uncomplicated disease in a non-pregnant patient is treated with a single 150 mg oral dose of fluconazole or a short course of a topical azole, per current CDC STI guidance.
Recurrent disease (>=4 episodes per year) is treated with induction followed by weekly fluconazole maintenance.
Why the others are wrong
Fluconazole 150 mg weekly for 6 months — the suppressive regimen for recurrent vulvovaginal candidiasis and only after induction dosing; this woman has a single uncomplicated episode that a one-time 150 mg dose clears. Sets the overtreatment trap.
Metronidazole 500 mg BID for 7 days — treats bacterial vaginosis and trichomoniasis, not candidiasis; the absence of clue cells and odor with the presence of yeast exclude it. Sets the premature-closure trap of defaulting to the most common vaginitis regimen.
Boric acid vaginally for 14 days — reserved for azole-refractory or non-albicans species such as C. glabrata, which do not form pseudohyphae; the KOH findings here are those of C. albicans. Sets the second-line-before-first-line trap.
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Candida is a normal vaginal commensal in ~20% of women. Disruption of microbial balance (e.g., antibiotic-induced loss of Lactobacillus), local immune changes, or substrate availability (hyperglycemia, glucosuria from SGLT2 inhibitors) permits overgrowth and hyphal invasion of vaginal epithelium, producing inflammation.
Severe disease: fluconazole 150 mg PO × 2 doses 72 hours apart, OR topical azole × 7-14 days
Recurrent (≥3 episodes/year): induction with fluconazole 150 mg q72h × 3 doses, then suppression with fluconazole 150 mg weekly × 6 months
Non-albicans (especially C. glabrata): intravaginal boric acid 600 mg suppositories nightly × 14 days OR nystatin vaginal tablets; resistant azoles
Ibrexafungerp (oral triterpenoid) — FDA-approved alternative for VVC and RVVC prevention
Pregnancy
Topical azoles only (clotrimazole, miconazole) × 7 days
Avoid oral fluconazole (associated with miscarriage at high doses; first-trimester safety concerns)
Complications
Recurrent infection (5-8%)
Vulvar excoriation and secondary bacterial infection
Persistent dyspareunia and quality-of-life impact
Increased risk of preterm delivery (controversial association in pregnancy)
PANCE pearls
Vaginal pH <4.5 helps distinguish candidiasis from BV (pH >4.5) and trichomoniasis (pH >4.5).
Treat the patient, not the lab — uncomplicated VVC may be diagnosed clinically; KOH wet mount has only ~50% sensitivity.
OTC azole self-treatment frequently fails (true VVC in only ~30% of women self-treating); confirm diagnosis when patients present with treatment failure.
Non-albicans species (especially C. glabrata) are often azole-resistant — boric acid is highly effective.
Recurrent VVC warrants evaluation for diabetes and consideration of HIV; also assess vulvar skin disease (lichen sclerosus) which may mimic chronic yeast infection.
Sexual partner treatment is not indicated for routine VVC.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.