Vulvovaginal Candidiasis
NICE CKS Candida – female genital. Last revised: Oct 2023.
BASHH Vulvovaginal Candidiasis 2019. Last updated: Jan 2021.
13/02/26: Partner management added under acute infection section
Definition
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)
Aetiology
Most common caused by 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)
- Immunosuppression
- 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)
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 for microscopy |
|
| Vaginal pH testing of secretions |
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| Midstream sample of urine |
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| HbA1c |
|
Management
Acute Infection
Choice of anti-fungal (both oral and topical treatment gives similar cure rates):
- 1st line: oral fluconazole (single dose)
- 2nd line: topical therapies
- Preferred: intravaginal clotrimazole pessary (single dose)
- Alternative: intravaginal antifungal creams (i.e, clotrimazole or miconazole)
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
Partner Management
| Asymptomatic partner | Contact tracing / treatment is NOT indicated |
| Symptomatic male partner | Suspected / confirmed candidal balanitis [Ref]
|
Recurrent Infection
Offer an induction-maintenance regimen:
- Induction: 3 doses of oral fluconazole – to be taken every 72 hours
- Maintenance: oral fluconazole once a week for 6 months
2nd line induction-maintenance regimen:
- Induction: topical clotrimazole intravaginal pessary up to 7-14 days
- Maintenance: topical clotrimazole intravaginal pessary once a week for 6 months OR oral itraconazole daily for 6 months
Infection During Pregnancy
Duration of treatment is 7 days (applied at night):
- 1st line: topical clotrimazole intravaginal pessary
- 2nd line: intravaginal anti-fungal creams (i.e, clotrimazole or miconazole)
Pregnant women generally need a longer duration of treatment (for 7 days) to clear the infection, as opposed to the single-dose treatment preferred in non-pregnant women.
Oral antifungals (including fluconazole) are generally contraindicated in pregnancy.
Topical antifungals are safe alternatives in pregnancy, as there is limited systemic absorption from the vagina.
References