Diagnosis: Vulvovaginal Candidiasis (VVC)

Note on the condom: Flavored condoms contain glycerin/sugars. These can alter vaginal pH and feed yeast overgrowth - this is a well-known trigger.

Confirming the Diagnosis

1. Vaginal pH - should be normal (< 4.5) in VVC (elevated pH suggests bacterial vaginosis instead)
2. KOH wet mount - look for budding yeast cells or pseudohyphae (positive in ~80% of cases)
3. Whiff test - should be negative (positive whiff = bacterial vaginosis)
4. Fungal culture if microscopy is negative but clinical suspicion remains high

Treatment

Option 1 - Oral (Preferred for convenience)

• Fluconazole 150 mg orally, single dose
• Equal efficacy to topical azoles for mild-moderate VVC
• Symptoms will persist 2-3 days after the dose - reassure the patient this is normal

Option 2 - Topical Azoles (OTC available)

Additional Points

• No need to treat the partner - VVC is not routinely sexually transmitted; male partners rarely need treatment unless they have symptomatic balanitis
• Advise against flavored condoms for vaginal intercourse going forward - they predispose to yeast infections
• If she fails fluconazole, consider non-albicans Candida (e.g., C. glabrata) and send a culture
• If symptoms recur 4+ times/year, consider recurrent VVC protocol: fluconazole 150 mg every 72 hours x 3 doses, then weekly for 6 months

How to Use Clotrimazole Vaginal Gel (Cream)

Which Regimen - Depends on Concentration

Step-by-Step Instructions for the Patient

1. Wash hands thoroughly before and after
2. Fill the applicator - load the cream into the provided applicator up to the marked line (5 g)
3. Lie down on your back with knees bent
4. Insert the applicator gently as far into the vagina as comfortable
5. Push the plunger slowly to release the cream
6. Remove the applicator and dispose (if single-use) or wash (if reusable)
7. Apply at bedtime - lying down helps the cream stay inside and not leak out
8. A thin layer can also be applied to the outside (vulvar area) to relieve the itching on the skin around the vagina

Important Counseling Points

• Complete the full course even if symptoms improve after day 1 or 2 - stopping early leads to recurrence
• Use at night/bedtime - this maximizes retention of the cream inside the vagina
• Avoid tampons, douches, and spermicides during treatment - they interfere with the medication
• Avoid sexual intercourse during the treatment days - the cream can weaken latex condoms and diaphragms, and sex can wash out the medication
• Expect mild burning or irritation for the first day or two - this is normal; about 1.6% of patients experience a mild burning sensation
• Symptoms fully resolve in 2-3 days typically, but keep using until the course is done

When to Return

• Symptoms do not improve after completing the full course
• Symptoms return within 2 months (may indicate non-albicans species or recurrent VVC)
• She develops fever, lower abdominal pain, or foul-smelling discharge (suggests a different or more serious infection)

Inserting Clotrimazole Gel Without an Applicator

Steps

1. Wash hands thoroughly with soap and water
2. Squeeze a sufficient amount of cream onto a clean fingertip (roughly a fingertip-sized amount, approximating the 5 g dose)
3. Lie on her back with knees bent, or squat
4. Insert the index finger as deep as comfortably possible into the vagina
5. Deposit the cream as far back (toward the cervix) as she can reach
6. Wipe off excess and wash hands again after

Practical Tips

• Trim and clean fingernails before inserting to avoid scratching the vaginal wall
• Bedtime is still best - lying down after insertion keeps the cream from sliding out
• She can apply any leftover cream to the external vulvar area (labia, outer opening) to help relieve the itching on the outside
• The internal dose won't be as precisely measured as with an applicator, but finger insertion is an accepted and effective alternative - it's the same method recommended for vaginal tablet insertion when no applicator is available

Better Long-Term Option

• Getting a replacement applicator from the pharmacy (many are sold separately)
• Switching to oral fluconazole 150 mg single dose - one tablet by mouth, no applicator needed, equally effective for uncomplicated VVC, and arguably simpler for most patients

Fluconazole Tablet - Dosing for VVC

Uncomplicated VVC (this patient)

• Fluconazole 150 mg - single dose, taken once
• That's it. Just one tablet, one day. No repeat needed.

Complicated / Severe VVC

• Fluconazole 150 mg - Day 1, then a second dose on Day 3 (72 hours apart)
• So just 2 tablets total, not daily for many days

Recurrent VVC (4+ episodes/year)

• Fluconazole 150 mg every 72 hours x 3 doses (induction), then
• 150 mg once weekly for 6 months (maintenance/suppression)