Reproductive · PANCE / PANRE

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)

VVC classification and treatment approach by CDC/ACOG.

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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