Candidal Vulvovaginitis
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.
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Risk factors
- Recent antibiotic use
- Diabetes mellitus (especially poorly controlled)
- Pregnancy (elevated estrogen)
- Immunosuppression (HIV, chemotherapy, high-dose steroids)
- Oral contraceptives with higher estrogen (modest)
- Tight synthetic clothing, occlusive perineum
- SGLT2 inhibitors (canagliflozin, empagliflozin, dapagliflozin)
Pathophysiology
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.
Clinical presentation
Symptoms
- Intense vulvar and vaginal pruritus (hallmark)
- Burning, soreness, irritation
- External dysuria (urine contacting inflamed vulva)
- Dyspareunia
- Thick white 'cottage cheese' discharge — odorless
Signs / physical exam
- Vulvar erythema and edema, possible satellite lesions
- Excoriations from scratching
- Adherent white plaques on vaginal walls
- No fishy odor
Classic findings
Woman after antibiotic use with severe vulvar itching, vulvar erythema, thick curd-like discharge, normal pH, and yeast/pseudohyphae on KOH prep.
Differential diagnosis
- Bacterial vaginosis — Thin gray discharge, fishy odor, pH >4.5, clue cells, minimal pruritus
- Trichomoniasis — Frothy yellow-green discharge, motile trichomonads, pH >4.5
- Atrophic vaginitis — Postmenopausal, dryness; thin pale mucosa
- Allergic / contact dermatitis — Recent product exposure; erythema and pruritus without discharge
- Lichen sclerosus / lichen planus — Chronic vulvar pruritus, atrophic 'cigarette paper' or erosive changes; biopsy
- Herpes simplex — Painful vesicles/ulcers, viral prodrome; PCR
- Vulvodynia — Pain without identifiable cause; normal exam
Diagnostic workup
Labs
- Vaginal pH normal (<4.5) — important distinguishing feature
- 10% KOH wet mount: budding yeast, pseudohyphae (C. albicans) or budding yeast without pseudohyphae (C. glabrata)
- Negative whiff test
- Culture if recurrent, severe, or atypical (identifies non-albicans species and resistance)
- Fasting glucose or A1c if recurrent — screen for undiagnosed diabetes
- HIV testing if unusual recurrence or severity
Diagnostic algorithm
| Category | Definition | First-line Treatment |
|---|---|---|
| Uncomplicated VVC | Sporadic, mild-moderate, C. albicans, immunocompetent host | Fluconazole 150 mg PO × 1 OR topical azole 1-7 d |
| Severe VVC | Extensive vulvar erythema, edema, excoriation, fissures | Fluconazole 150 mg × 2 doses 72 h apart OR topical 7-14 d |
| Recurrent VVC | ≥3 episodes/year | Induction (3 doses fluconazole) + weekly suppression × 6 mo |
| Non-albicans VVC | C. glabrata, C. krusei, etc. | Boric acid 600 mg PV × 14 d, nystatin, ibrexafungerp |
| Pregnancy | Any trimester | Topical clotrimazole or miconazole × 7 d (no oral fluconazole) |
Treatment
First-line
- Uncomplicated: fluconazole 150 mg PO × 1 dose
- Topical azole alternatives × 1-7 days: clotrimazole, miconazole, terconazole, tioconazole (available OTC)
- Patient symptom relief usually within 24-48 hours
Complicated VVC (severe, recurrent, non-albicans, immunocompromised, pregnancy)
- 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.
References
- CDC STI Guidelines 2021 — CDC Sexually Transmitted Infections Treatment Guidelines, 2021 (MMWR Recomm Rep 2021)
- ACOG PB 215 — ACOG Practice Bulletin No. 215: Vaginitis in Nonpregnant Patients
- IDSA 2016 — Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the IDSA (Pappas et al., CID 2016)
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