Whitish discharge per vagina with itching.. Dx?

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vulvovaginal candidiasis white discharge cottage cheese

Clinical photography of the external female genitalia demonstrating vulvar mucosal inflammation with characteristic white curd-like plaques consistent with candidal vulvovaginitis. The view focuses on the labia majora and vestibular mucosa, highlighting diffuse erythema, edema, and superficial fissuring surrounding adherent, cottage-cheese-like plaques. The image captures the hallmark appearance of vulvovaginal candidiasis: intense itching, burning, and soreness often accompanying a thick, whitish discharge, though discharge quality may vary. From a diagnostic perspective, this photograph supports a clinical suspicion of Candida species infection, particularly Candida albicans, in an immunocompetent or mildly compromised host. Correlation with microscopy (KOH prep) and culture, or rapid antigen tests, can confirm budding yeast and pseudohyphae within mucosal epithelium. Normal vulvar variants are unlikely given erythema and plaque formation. Differential diagnoses include irritant contact dermatitis, bacterial vaginosis, and trichomoniasis, but the discrete white plaques favor fungal etiology. Timely antifungal therapy, such as azole antifungals, usually yields rapid improvement; recurrence prompts evaluation for diabetes, antibiotic exposure, or immunosuppression. This image is relevant for medical education, dermatology and gynecology training, clinical decision support, and research on vulvar infections, mucosal candidiasis pathophysiology, and patient counseling about symptom management and prevention. Educational value includes differential diagnosis, treatment guidelines, and patient education resources handouts.

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Here is a structured clinical answer:

Whitish Vaginal Discharge + Itching

Most Likely Diagnosis: Vulvovaginal Candidiasis (VVC)

The combination of white discharge + pruritus (itching) is the hallmark of VVC, caused most commonly by Candida albicans.

Vulvovaginal Candidiasis - white curd-like plaques with erythema

Differential Diagnosis of Vaginal Discharge with Itching

Condition	Discharge	Itching	Odor	pH	Key Test
Candidiasis (VVC)	Thick, curd-like/cottage cheese, white	Prominent	None	3.8-4.5 (normal)	KOH prep: pseudohyphae + budding yeast
Bacterial Vaginosis (BV)	Thin, gray, homogenous	Mild/absent	Fishy (amine)	>4.5	Saline: clue cells; positive whiff test
Trichomoniasis	Frothy, yellow-green, profuse	Moderate	Fishy	6-7	Saline: motile trichomonads
Atrophic vaginitis	Thin, watery	Burning/dryness	None	>4.5	History (postmenopausal)
Allergic/Contact vaginitis	Variable	Prominent	None	Any	History (irritant exposure)

Harrison's Principles of Internal Medicine 22E, Table 141-5
Textbook of Family Medicine 9e, Table 25-7

Candidiasis: Clinical Features

Discharge: thick, white, "cottage cheese" or curd-like; non-malodorous
Itching/Pruritus: the dominant symptom - often intense
Vulvar erythema, edema, fissures, dyspareunia, external dysuria
pH: normal (3.8-4.5) - distinguishes from BV and Trichomonas
KOH prep (10%): pseudohyphae and budding yeast cells

Causative organism: Candida albicans (most common), also C. glabrata, C. tropicalis

Risk Factors for VVC

Recent antibiotic use (disrupts normal lactobacilli flora)
Diabetes mellitus (uncontrolled)
Pregnancy
Immunosuppression (HIV, corticosteroids)
Oral contraceptive use
Tight synthetic clothing, poor hygiene

Treatment

Setting	Drug	Dose
Uncomplicated (first-line)	Clotrimazole pessary/cream (topical)	500 mg single dose vaginal pessary; or 1% cream for 7 days
Oral option	Fluconazole	150 mg single oral dose
Recurrent VVC (≥4 episodes/year)	Fluconazole	150 mg every 72h x3, then weekly for 6 months
Pregnancy	Topical azoles only (fluconazole avoided in 1st trimester)	7-day course

Quick Diagnostic Workup

Vaginal pH - normal (≤4.5) favors candidiasis; >4.5 favors BV/Trichomonas
KOH wet mount (10%) - pseudohyphae + yeast (confirms candidiasis)
Saline wet mount - rules out Trichomonas (motile organisms) and BV (clue cells)
Whiff/amine test - positive in BV, negative in VVC
Culture if recurrent/resistant (to identify C. glabrata - azole-resistant)

Bottom line: Whitish discharge + itching without odor + normal pH = Vulvovaginal Candidiasis until proven otherwise. Confirm with KOH prep and treat with topical or oral azole.

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Treatment of Vulvovaginal Candidiasis

1. Uncomplicated VVC

(First episode / infrequent / mild-moderate / non-pregnant / immunocompetent)

Oral (Systemic) - Preferred by most patients:

Drug	Dose	Duration
Fluconazole	150 mg PO	Single dose

Topical Intravaginal Azoles (equally effective, ~80-90% cure):

Drug	Formulation	Regimen
Clotrimazole	1% cream	1 applicator intravaginally at bedtime x 7 days
Clotrimazole	2% cream	1 applicator intravaginally at bedtime x 3 days
Miconazole	2% cream	1 applicator intravaginally at bedtime x 7 days
Miconazole	4% cream	1 applicator intravaginally at bedtime x 3 days
Terconazole	0.4% cream	1 applicator intravaginally at bedtime x 7 days
Terconazole	80 mg suppository	1 suppository intravaginally at bedtime x 3 days
Tioconazole	6.5% ointment	Single intravaginal dose
Nystatin	100,000-unit vaginal tablet	1 tablet at bedtime x 14 days (less effective)

Topical azoles > nystatin in efficacy. All formulations (creams, suppositories, tablets) are equally effective.

Tintinalli's Emergency Medicine, Table 102-5
Harrison's 22E

2. Complicated VVC

(Recurrent ≥4 episodes/year, severe symptoms, C. glabrata, pregnant, or immunocompromised)

Recurrent VVC (RVVC) - Induction + Maintenance:

Phase	Drug	Dose
Induction	Fluconazole 150 mg PO	Every 72 hours x 3 doses (Day 1, 4, 7)
Maintenance	Fluconazole 150 mg PO	Once weekly x 6 months

Severe VVC:

Fluconazole 150 mg PO x 2 doses, 72 hours apart

3. Pregnancy

Topical azoles ONLY - 7-day course (extended duration)
Fluconazole is CONTRAINDICATED in pregnancy (teratogenic risk in 1st trimester, Category C)
Clotrimazole or miconazole topical preferred

4. C. glabrata / Azole-Resistant VVC

Boric acid 600 mg vaginal capsule at bedtime x 14 days
Nystatin vaginal suppositories
Flucytosine vaginal cream (specialist use)

5. Partner Treatment

Routine treatment of male partner is NOT indicated
Treat only if male partner has symptomatic candidal balanitis

Key Points

Topical azoles = Oral fluconazole in efficacy for uncomplicated cases
Oral fluconazole is more convenient (single dose, patient preference)
Treat underlying risk factors: control diabetes, limit unnecessary antibiotics, avoid tight synthetic clothing
If no response to standard treatment - culture to identify C. glabrata or C. krusei (intrinsically azole-resistant)

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