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Candida - female genital - Management
How should I manage vulvovaginal candidiasis in women who have poorly controlled diabetes or who are immunocompromised?

  • For women who have poorly controlled diabetes or who are are immunocompromised (e.g. receiving immunosuppressant drugs such as long-term corticosteroids, or with HIV/AIDS):
    • Correct modifiable conditions (e.g. uncontrolled diabetes).
    • Give general advice to avoid local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
    • Treat with long courses (7 days) of oral antifungals (e.g. fluconazole or itraconazole), or intravaginal antifungals (e.g. clotrimazole, econazole, or miconazole) for 6–14 days.
    • Choice of treatment will depend upon a number of factors, including the woman's preference.
    • For vulval symptoms, consider using a topical imidazole cream (e.g. clotrimazole, or econazole), in addition to an oral or intravaginal antifungal.
    • For girls aged between 12 and 16 years, offer a 7 day course of an oral antifungal (fluconazole or itraconazole).
      • However, an intravaginal antifungal may be considered if the girl is sexually active, if tampons are being used, or if there is no other alternative.
  • Advise the woman to return if:
    • Symptoms have not resolved within 7–14 days.
    • She becomes systemically unwell.
Clarification / Additional information
  • Treatment of vulvovaginal candidiasis in HIV-infected women who are not immunocompromised is the same as that for HIV–negative women.
  • Treatment of women with well-controlled diabetes is the same as that for women without diabetes.
Basis for recommendation
  • These recommendations are based on expert opinion published in the medical literature [CDC, 2006].
  • Women with underlying debilitating medical conditions such as uncontrolled diabetes, or those receiving immunosuppressive drugs (e.g. corticosteroid treatment), do not respond as well to short-term therapies [CDC, 2006].
  • Girls aged 12–16 years:
    • Experts consider that oral antifungals are generally more appropriate than intravaginal antifungals in this age group. However, an intravaginal antifungal may be appropriate for girls who are sexually active or using tampons, or if there is no alternative [BNF for Children, 2007; Daniels, Personal Communication, 2007].
  • Adverse effects:
    • There is evidence from a number of randomized controlled trials that vulval burning and vaginal discharge are more common with intravaginal imidazoles, whilst nausea, headache, and abdominal pain are more common with oral imidazoles.
    • There is no evidence that antifungal treatments used appropriately have serious adverse effects.
  • Treatments not recommended:
    • Topical nystatin. There is evidence that topical nystatin is effective for treating uncomplicated vulvovaginal candidiasis. Nystatin preparations give a 70–90% cure rate. However, it is not normally recommended for uncomplicated vulvovaginal candidiasis, as it is given as a 14-day intravaginal regimen and may stain clothes yellow [FFPRHC and BASHH, 2006].
    • Oral ketoconazole. The MHRA has advised that ketoconazole tablets should only be initiated by a physician who is experienced in the management of fungal infections because of the risk of serious hepatotoxicity. Oral ketoconazole should only be prescribed for the treatment of chronic mucocutaneous candidosis that cannot be treated topically because of the site, extent of the lesion, or deep infection of the skin, in people resistant to or intolerant of both fluconazole and itraconazole [MHRA, 2008].
    • Povidone-iodine is an antiseptic available in topical intravaginal formulations and is licensed for the treatment of candidal infections of the vagina. However, there is little published evidence to support its use.

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