Background Information

Definitions

Vulvovaginal candidiasis (genital thrush): symptomatic inflammation of the vagina and/or vulva secondary to fungal infection.

Recurrent infection: ≥4 symptomatic episodes in 1 year, at least 2 confirmed by microscopy / culture (at least one by culture)

Causative Agent

Most common genus: Candida yeasts

• Most common species: Candida albicans (80-89% cases)
• Candida glabrata (5%)

Risk Factors

• Local irritants – douching, soaps, shampoos, shower gels
• Recent antibiotic use (within 3 months)
• Immunosupression
  • Poorly controlled diabetes mellitus
  • HIV infection
  • Long-term corticosteroid use
• Oestrogen exposure
  • Pregnancy
  • COCP
  • HRT

Clinical Features

Possible symptoms:

• Vulval / vaginal itching (most common), soreness and irritation
• Superficial dyspareunia and dysuria

On examination:

• White ‘cheese-like’ discharge (non-malodorous)
• Erythema
• Vaginal fissuring and/or oedema
• Excoriations
• Satellite lesions (often associated with more severe/extensive disease)

Guidelines

Investigation and Diagnosis

Clinical diagnosis is usually sufficient in the presence of typical signs and symptoms.

Consider the following for recurrent infection / diagnostic uncertainty:

• High vaginal swab of vaginal secretions for microscopy 
  • Self-collected low vulvovaginal swab is also appropriate (if examination of external genitalia not possible or not needed)
  • Culture might be needed for recurrent infection
• Vaginal pH testing of secretions
  • Normal pH (<4.5) supports candidiasis
  • Not needed for diagnosis, but helpful to exclude bacterial vaginosis and trichomoniasis
• Midstream sample of urine 
  • If UTI is suspected
• HbA1c – to exclude diabetes mellitus (esp. if recurrent infections)

Management

Acute Infection

Choice of anti-fungal (both oral and topical treatment gives similar cure rates):

• 1st line: oral fluconazole 150mg single dose
• 2nd line: topical clotrimazole 500mg intravaginal pessary single dose

If there are vulval symptoms: consider adding topical clotrimazole 1% / 2% cream 2-3 times a day

Treatment Failure

Definition: if no response to initial treatment within 7-14 days

• Perform a high vaginal swab 
• Treat according to high vaginal swab results

Recurrent Infection

Offer an induction-maintenance regimen:

• Induction: 3 doses of oral fluconazole 150mg – to be taken every 72 hours
• Maintenance: oral fluconazole 150mg once a week for 6 months

2nd line induction-maintenance regimen:

• Induction: topical clotrimazole 500mg intravaginal pessary up to 7-14 days
• Maintenance: topical clotrimazole 500mg intravaginal pessary once a week for 6 months OR oral itraconazole 50-100mg daily for 6 months

Infection During Pregnancy

Choice of anti-fungal:

• 1st line: topical clotrimazole intravaginal pessary at night for up to 7 consecutive nights

If there are vulval symptoms: consider adding topical clotrimazole 1% / 2% cream 2-3 times a day

References