Asymptomatic Yeast Vaginitis Unresponsive to OTC Treatment

Miss R, a 22-year-old G0 patient comes in for a focus visit.  She is complaining of vaginal burning and discharge that has lasted for one week.  She has tried over-the-counter (OTC) yeast infection medication but “nothing has helped.”

EXAMINATION
On physical pelvic exam:

                Vulva: Inflammation, excoriations consistent with scratching

                Vagina: Large amount thick white discharge

                Cervix: Clear

                Uterus: Anteverted, mobile, non-tender

                Adnexa: Ovaries palpated, normal size

                Wet Prep: Yeast hyphae on KOH prep;  NaCl reveals clumping of epithelial cells and WBCs

ASSESSMENT
Miss R is diagnosed with vulvo-vaginal candidiasis. She has tried OTC medications for her symptoms, but most of these medications treat only Candida albicans infection. Oral Diflucan 150mg is not recommended, as it offers only intermediate efficacy against Candida glabrata (Torulopsis glabrata), the second most common cause of asymptomatic vaginal candidiasis after Candida albicans.  

TREATMENT PLAN
Miss R is prescribed a weeklong course of vaginal terconazole cream to be applied at bedtime that will treat Candida glabrata and other strains of vaginal yeast, and is advised to return to the clinic for follow-up after completion of therapy.