Vaginal candidiasis

Question 1

What is prescribed to treat vulvovaginal candidiasis in pregnant and non-pregnant women?

Answer 1

Non-pregnant

Antifungal treatment: can be local or oral

Local -

• clotrimazole pessary or cream (e.g. clotrimazole 500 mg PV stat)

Oral -

• itraconazole 200 mg PO BD for 1 day OR
• fluconazole 150 mg PO stat

Pregnant

Antifungal treatment: topical only

• intravaginal clotrimazole (e.g. clotrimazole 500 mg PV stat)

Question 2

Do candidiasis treatments need to be prescribed?

Answer 2

No they are mostly all over the counter including:

• intravaginal clotrimazole (Canesten),
• oral fluconazole,
• topical clotrimazole

Question 3

If the patient has vulval symptoms, what should you add to the oral or intravaginal treatment?

Answer 3

Vulval symptoms:

topical imidazole (clotrimazole, ketoconazole)

….in addition to an oral or intravaginal antifungal

Question 4

What should you prescribe for 12-15 year olds with vulvovaginal candidiasis? What should not be prescribed?

Answer 4

Girls aged 12-15 years:

• consider prescribing topical clotrimazole 1% or 2% applied 2-3 times per day

(do not prescribe intravaginal or oral antifungal)

Question 5

What lifestyle advice can be given to prevent recurrence of thrush?

Answer 5

Avoid predisposing factors:

• Washing and cleaning the vulval area with soap or shower gels, wipes and feminine hygiene products*
• Cleaning the vulval area more than once per day
• Washing underwear in biological washing powder and using fabric conditioners
• Vaginal douching
• Wearing tight-fitting and/or non-absorbent clothing

*Wash the vulval area with a soap substitute - used externally and not more than once per day

Use simple emollient to moisturise vulval area

Consider probiotics (e.g. live yoghurts) orally or topically to relieve symptoms

Question 6

Do partners need treatment too?

Answer 6

Do not routinely treat asymptomatic sexual partner BUT male partner could get candida balanitis

Question 7

When should you ask the patient to return if symptoms have not resolved?

Answer 7

Return if symptoms have not resolved in 7-14 days

Question 8

List 4 risk factors for vaginal candidiasis.

Answer 8

1. diabetes mellitus
2. drugs: antibiotics, steroids
3. pregnancy
4. immunosuppression: HIV

Question 9

What are the clinical features of vulvovaginal candidiasis?

Answer 9

• ‘cottage cheese’, non-offensive discharge
• vulvitis: superficial dyspareunia, dysuria
• itch
• vulval erythema, fissuring, satellite lesions may be seen

Question 10

What investigations are needed in candidiasis?

Answer 10

None - clinical diagnosis

Sometimes a high vaginal swab may be done

Question 11

Define recurrent vaginal candidiasis.

Answer 11

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year

Question 12

What investgations should you consider in recurrent candidiasis?

Answer 12

confirm the diagnosis of candidiasis

• high vaginal swab for microscopy and culture
• consider a blood glucose test to exclude diabetes

+ exclude differential diagnoses such as lichen sclerosus

Question 13

What is the management of recurrent candidiasis?

Answer 13

consider the use of an induction-maintenance regime

1. induction: oral fluconazole every 3 days for 3 doses
2. maintenance: oral fluconazole weekly for 6 months

Question 14

What % of thrush is caused by candida albicans?

Answer 14

Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.