Candida—Female Genital

Overview

This updated summary has been developed for use by community pharmacists under our Guidelines for Pharmacy title and therefore only covers the information relevant to this setting. Recommendations included cover the definition, assessment, and management of acute and recurrent vulvovaginal candidiasis. Please refer to the full Clinical Knowledge Summary for the complete set of recommendations.

What Is It?

• Vulvovaginal candidiasis (genital thrush) is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection (usually yeasts that belong to the genus Candida)
• Acute infection describes a first or single isolated presentation of vulvovaginal candidasis, and Candida species is usually detected by microscopy and/or culture.
• Recurrent infection describes four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic (at least one must be culture). 
• Treatment failure is defined as failure of symptoms to resolve within 7–14 days of treatment.

What Are the Complications?

• Treatment failure — occurs in up to 10–20% of women receiving imidazole treatment for acute infection.
• Recurrent infection — women may have a poor or partial response to therapy with persistence of symptoms between treatments.
• Reduced quality of life and psychosexual difficulties — including embarrassment, reduced libido and arousal may affect women who have recurrent infection.
• Candidal balanitis — may occur rarely in male partners of women with vulvovaginal candidiasis. This typically presents with erythematous areas on the glans of the penis, pruritus, and/or irritation.

How Should I Assess a Woman with Suspected Vulvovaginal Candidiasis?

• If a woman has suspected vulvovaginal candidiasis:
  • Ask about:
    • The duration and severity of symptoms, such as:
      • Vulval or vaginal itching (often the defining symptom).
      • Vulval or vaginal soreness and irritation.
      • Vaginal discharge (usually white, 'cheese-like', and non-malodorous).
      • Superficial dyspareunia.
      • Dysuria (pain or discomfort during urination).
    • The frequency of symptoms:
      • An isolated episode, or
      • Recurrent symtoms, or
      • Treatment failure.
    • Any risk factors for candidiasis.
    • Any risk factors for a sexually transmitted infection (STI), if appropriate. See the CKS topic on Vaginal discharge for more information on risk factors.
    • Any treatments tried, including over-the-counter treatments.
    • Risk of pregnancy and contraceptive use.
    • Other symptoms which may indicate an alternative or additional diagnosis:
      • Foul smelling or purulent discharge could indicate a bacterial infection. See the CKS topic on Bacterial vaginosis for more information.
      • Urinary frequency and urgency could indicate a urinary tract infection (UTI) or STI. See the CKS topics on Urinary tract infection (lower) - women and Vaginal discharge for more information.
      • Abnormal vaginal bleeding could indicate an STI or gynaecological cancer. See the CKS topic on Gynaecological cancers - recognition and referral for more information.
      • Other recurrent infections may indicate possible immunosuppression.

        For more recommendations on assessment, refer to the full Clinical Knowledge Summary.

Acute Vulvovaginal Candidiasis

How Should I Manage Acute Vulvovaginal Candidiasis?

• If a woman presents with an episode of acute vulvovaginal candidiasis:
  • Offer advice on sources of information and support, such as:
    • The NHS leaflet Thrush in men and women.
    • The patient.info leaflet Vaginal thrush.
  • Advise on self-management measures to provide symptom relief:
    • Use simple emollients as a soap substitute to wash and/or moisturize the vulval area.
    • Avoid contact with potentially irritant soap, shampoo, bubblebath, or shower gels, wipes, and daily or intermenstrual 'feminine hygiene' pad products.
    • Avoid vaginal douching.
    • Avoid wearing tight-fitting and/or non-absorbent clothing, which may irritate the area.
    • Avoid use of complementary therapies such as application of yoghurt, topical or oral probiotics, and tea tree or other essential oils.
  • If a woman has uncontrolled diabetes mellitus or is otherwise immuncompromised:
    • Optimize management of any underlying conditions causing immunocompromise if possible. See the CKS topics on Diabetes - type 1, Diabetes - type 2, and HIV infection and AIDS for more information.
  • Advise on antifungal drug treatment options and preparations, depending on the woman's age, co-morbidities, personal preference, and drug cautions and contraindications.
    • Advise fluconazole 150 mg oral capsule as a single dose first-line.
    • Advise clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated. See the section on Oral fluconazole in Prescribing information for more information on drug contraindications and cautions.
      • Advise that topical imidazole preparations may damage latex condoms and diaphragms.
    • Note: if these treatment options are not tolerated or contraindicated, see the section on Alternative treatment regimens in the full Clinical Knowledge Summary for more information.
    • See the section on Prescribing information for detailed information on oral, intravaginal, and topical antifungals, including contraindications and cautions, adverse effects, and drug interactions.
  • If there are vulval symptoms, consider advising on use of a topical imidazole in addition to an oral or intravaginal antifungal. 
    • Options include clotrimazole 1% or 2% cream applied 2–3 times a day.
    • Advise that oral fluconazole, intravaginal clotrimazole, and topical clotrimazole can be bought over-the-counter.
      • Advise that topical imidazole preparations may damage latex condoms and diaphragms.
  • If there are signs of severe infection, advise to repeat antifungal drug treatment after 72 hours:
    • Prescribe fluconazole 150 mg oral capsule on day 1 and 4 first-line.
    • Note: if this treatment option is not tolerated or contraindicated, see the section on Alternative treatment regimens in the full Clinical Knowledge Summary for more information. 
  • Arrange follow-up if symptoms have not resolved within 7–14 days or if symptoms are recurrent.
    • Advise that follow-up and test of cure are not necessary if symptoms have resolved.
    • Do not routinely treat an asymptomatic male sexual partner. If a woman's male partner has suspected balanitis, see the CKS topic on Balanitis for more information on diagnosis and management.

How Should I Manage Treatment Failure of Acute Vulvovaginal Candidiasis?

• If a woman has acute vulvovaginal candidiasis which has not responded to initial treatment within 7–14 days:
  • Check that initial treatment was used as recommended.
    • Be aware that topical treatments can cause vulvovaginal irritation, which may be mistaken for treatment failure. See the section on Topical antifungals in Prescribing information for more information.
  • Reassess for risk factors for persistent or recurrent infection, and manage appropriately.
  • Arrange an examination of the external genitalia (if not already performed) with high vaginal swab (HVS), and arrange other investigations to assess for an alternative or additional diagnosis, depending on clinical judgement.
  • Treat any ongoing infection, depending on the HVS result.
    • If there has been poor compliance with initial treatment, prescribe an alternative preparation (for example, prescribe oral treatment instead of intravaginal treatment).
  • Reinforce self-management advice for symptom relief.
  • Arrange specialist referral or seek specialist advice, depending on clinical judgement, if:
    • An affected young person is aged 12–15 years.
    • There is uncertainty about the diagnosis.
    • Symptoms are not improving and treatment failure is unexplained.
    • Symptoms persist after a second course of antifungal treatment.
    • The woman has uncontrolled diabetes and treatment failure.

How Should I Manage Treatment Failure of Acute Vulvovaginal Candidiasis?

• If a woman has acute vulvovaginal candidiasis which has not responded to initial treatment within 7–14 days:
  • Check that initial treatment was used as recommended.
    • Be aware that topical treatments can cause vulvovaginal irritation, which may be mistaken for treatment failure. See the section on Topical antifungals in Prescribing information in the full Clinical Knowledge Summary for more information.
  • Reassess for risk factors  for persistent or recurrent infection, and manage appropriately.
  • Arrange an examination of the external genitalia (if not already performed) with high vaginal swab (HVS), and arrange other investigations  to assess for an alternative or additional diagnosis, depending on clinical judgement.
  • Treat any ongoing infection, depending on the HVS result.
    • If there has been poor compliance with initial treatment, prescribe an alternative preparation (for example, prescribe oral treatment instead of intravaginal treatment).
  • Reinforce self-management advice for symptom relief.
  • Arrange specialist referral or seek specialist advice, depending on clinical judgement, if:
    • An affected young person is aged 12–15 years.
    • There is uncertainty about the diagnosis.
    • Symptoms are not improving and treatment failure is unexplained.
    • Symptoms persist after a second course of antifungal treatment.
    • The woman has uncontrolled diabetes and treatment failure.

Recurrent Vulvovaginal Candidiasis

How Should I Manage Recurrent Vulvovaginal Candidiasis?

• If a woman presents with recurrent vulvovaginal candidiasis:
  • Offer advice on sources of information and support, such as:
    • The NHS leaflet Thrush in men and women.
    • The patient.info leaflet Treating recurring yeast infections.
  • Reinforce advice on self-management measures to provide symptom relief.
  • Reassess for risk factors for persistent or recurrent infection, and manage appropriately.
  • Arrange an examination of the external genitalia with high vaginal swab (HVS), and arrange other investigations to assess for an alternative or additional diagnosis, depending on clinical judgement.
  • Offer an induction regimen immediately followed by maintenance treatment, the drug treatment and preparation depending on the woman's age, co-morbidities, and personal preference, and drug cautions and contraindications.
    • For induction, prescribe three doses of oral fluconazole 150 mg (to be taken every 72 hours) first-line.
    • For maintenance, prescribe oral fluconazole 150 mg once a week for six months first-line.
    • Note: if these treatment options are not tolerated or contraindicated, see the section on Alternative treatment regimens for more information.
    • Note: routine use of a topical imidazole in addition to an oral or intravaginal antifungal for vulval symptoms is not recommended.
    • See the section on Prescribing information in the full Clinical Knowledge Summary for detailed information on oral, intravaginal, and topical antifungals, including contraindications and cautions, adverse effects, and drug interactions.
  • Arrange follow-up if there is a poor or partial response to maintenance treatment. See the section on Follow-up for more information.
    • Do not routinely treat an asymptomatic male sexual partner. If a woman's male partner has suspected balanitis, see the CKS topic on Balanitis for more information on diagnosis and management.

How Should I Follow-up Recurrent Vulvovaginal Candidiasis?

• If a woman has completed an induction and maintenance regimen of treatment for recurrent vulvovaginal candidiasis:
  • If there are recurrent symptoms between maintenance treatment doses, options include:
    • Oral fluconazole 150 mg twice-weekly instead of once a week, or
    • Considering the use of cetirizine 10 mg once daily for six months, particularly if there is a history of allergy (off-label indication).
  • If there is a poor or partial response to maintenance therapy:  
    • Check concordance with therapy.
    • Arrange a high vaginal swab (HVS) and request culture with full speciation and sensitivity testing (if not already requested), and treat accordingly.
      • If HVS culture is negative and symptoms persist, consider assessment for an alternative diagnosis.
      • If a non-albicans Candida species or azole resistant Candida is identified, seek specialist advice.
  • If there are infrequent further sporadic episodes of vulvovaginal candidiasis, treat each episode as an acute infection.
    • See the section, Acute vulvovaginal candidiasis for more information.
  • If there is further recurrent vulvovaginal candidiasis,  consider the use of a repeat induction and maintenance treatment regimen if clinically indicated.
  • Arrange specialist referral or seek specialist advice, depending on clinical judgement, if:
    • An affected young person is aged 12–15 years.
    • There is uncertainty about the diagnosis.
    • A non-albicans Candida species or azole resistant Candida is identified.
    • A woman has uncontrolled diabetes and recurrent infection.

For recommendations on alternative treatment regimens, and managing vulvovaginal candidiasis during pregnancy, refer to the full Clinical Knowledge Summary.