Evaluation and Management of Genital Itching with Negative STI Testing

Diagnostic Approach

The Centers for Disease Control and Prevention recommends that with all STI testing negative, the most likely diagnoses are vulvovaginal candidiasis, contact/irritant dermatitis, or lichen sclerosis, and empiric treatment with topical antifungal therapy is the appropriate first-line approach 1, 2
Vulvovaginal candidiasis is characterized by pruritus, vulvovaginal erythema, white discharge, and burning, and is the most common infectious cause when STI testing is negative 1, 2
Residual symptoms from treated infection, such as pruritus, may persist for several weeks even after successful treatment 3

The Centers for Disease Control and Prevention recommends empiric treatment for vulvovaginal candidiasis even without confirmed yeast on microscopy, given the high prevalence and the fact that microscopy misses 20-50% of cases 1, 2
Topical antifungal therapy, such as clotrimazole 1% cream or miconazole 2% cream, is the recommended first-line treatment for vulvovaginal candidiasis 1, 2
Fluconazole 150mg oral is a convenient option for treating vulvovaginal candidiasis 1

If symptoms persist after 2 weeks of antifungal treatment, re-examination and consideration of culture for Candida species is recommended 1, 2
If symptoms recur within 2 months, medical evaluation is necessary to rule out recurrent VVC or alternative diagnoses 1, 5

For pregnant patients, only topical azole therapy for 7 days is recommended, and oral fluconazole should be avoided 2
For patients with recurrent episodes (≥4 per year), longer initial treatment and maintenance therapy with fluconazole or clotrimazole may be necessary 1, 5