Vulvovaginal candidiasis diagnosis and management

Last updated: June 2013

Diagnosis

Microscopy, culture and clinical presentation

Spores or hyphae detected on a wet preparation or Gram stain from a high vaginal swab (60 to 70% sensitivity), and/or positive culture

and

Symptoms and/or signs of vulvovaginitis, eg vaginal discharge, vaginal itch or discomfort, external dysuria, vulvo-vaginal erythema, vulvar fissuring and satellite lesions.

Note: Vulvovaginal candidiasis is usually (80 to 90%) caused by Candida albicans. Other candida species or yeasts such as C. glabrata, C. tropicalis, C. krusei, C.parapsilosis and Saccharomyces cerevisiae may also cause infection.

Treatment

Treatment uncomplicated vulvovaginal candidiasis

Treatment is only indicated for symptomatic women, as 10 to 20% of asymptomatic women in reproductive years may be colonised with Candida sp.

All topical and oral azole therapies give a clinical and mycological cure rate of over 80%.

Standard therapy

Clotrimazole 200 mg pessaries intravaginally at night for 3 nights (A)

OR

Clotrimazole 100 mg pessaries or cream 1% intravaginally at night for 6 nights (A)

OR

Miconazole 100 mg pessaries or cream 2% intravaginally at night for 6 nights (A)

OR

Fluconazole 150 mg orally as a single dose (D).

Topical azoles can cause local vulvovaginal irritation or burning.

Oral azoles (particularly itraconazole and ketoconazole), have rarely been associated with elevation of liver enzymes and drug-induced hepatitis.

Oral azoles have several clinically important drug interactions, including anecdotal reports of oral contraceptive failure with prolonged oral azole use.

Patient education

The following points should be discussed:

• The nature of the infection.
• The need for adequate hygiene and avoidance of potential irritants.
• Sexual transmission has negligible significance in the aetiology of vulvovaginal candidiasis. Sex partners do not need to be examined and treated.
• Topical vaginal preparations such as azoles are generally oil-based and will perish condoms and diaphragms within a short time. These preparations should not be inserted into the vagina prior to condom use.

Follow up

Required if symptoms do not resolve or symptoms recur.

Recurrent vulvovaginal candidiasis

Clinical features are identical to acute vulvovaginal candidiasis. Approximately 5% of women of reproductive age with a primary episode of VVC will develop recurrent VVC.

Diagnosis

The occurrence of at least four documented symptomatic episodes of vaginal candidiasis within 12 months, including two mycologically proven episodes

and

The exclusion of other common vaginal pathogens.

Management

Exclude or manage associated factors such as:

• high oestrogen states, such as pregnancy, the combined oral contraceptive pill or HRT
• uncontrolled diabetes mellitus,
• hormone therapy (including oestrogens or corticosteroids),
• HIV infection, other causes of immunosuppression, and
• repeated courses of broad-spectrum antibiotics.
• non-albicans sp. resistant to standard therapy
• avoid use of soap on genital skin. Plain water is advised for daily washing, but soap substitutes can be used such as QV Wash, Cetaphil or aqueous cream
• avoid tight-fitting or synthetic underwear, and vaginal douches or vaginal deodorants.

Treatment

• The principle aim is induction of remission followed by a prolonged period of maintenance therapy. Oral azoles should not be used in pregnancy or breastfeeding.
• 30 to 50% of women will have recurrent disease after maintenance therapy is discontinued.
• Routine treatment of partners is unlikely to reduce recurrence rates.

Induction therapy

7 to 14 days of topical therapy (as above)

OR

Fluconazole 150 mg orally every third day for a total of 3 doses [day 1, 4, and 7] (D).

Maintenance therapy

Clotrimazole 500 mg pessaries intravaginally at night, once weekly for six months (A)

OR

Fluconazole 150 mg orally once weekly for six months (D)

OR

Itraconazole* 50 to 100mg orally daily for six months (B3)

OR

Ketoconazole 100 mg orally daily for six months (B3) (monitor LFTs).

Complicated vulvovaginal candidiasis

This may occur in the following:

• non albicans species not responding to standard therapy and may require referral to a specialist
• infection in immunosuppressed persons.

Further information

For further information on the diagnosis and management of vulvovaginal candidiasis contact Clinic 275.

Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Clinic 275 staff and some flexibility is required in applying them to certain private practice situations.