Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

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

  • Review:
    • Check that treatments have been used as recommended.
    • Consider alternative diagnoses.
    • Reassess for other predisposing risk factors, and remove or control as far as possible.
  • Investigate:
    • Send a vaginal specimen for culture to identify:
      • A non-albicans Candida species.
      • A mixed infection such as candidiasis together with bacterial vaginosis or trichomoniasis (up to 10% of infections are mixed). See the CKS topics on Bacterial vaginosis and Trichomoniasis.
  • Manage:
    • Give general advice about avoiding local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
    • If non-compliance has been a problem with an intravaginal imidazole, prescribe a course (7 days) of an oral antifungal (e.g. fluconazole or itraconazole).
    • If non-compliance has been a problem with oral antifungal, then prescribe a course (6–14 days) of intravaginal imidazoles (e.g. clotrimazole, econazole, or miconazole).
    • For vulval symptoms, consider prescribing a topical imidazole cream (clotrimazole or econazole) in addition to an oral or intravaginal imidazole.
    • For girls between 12 and 16 years old, offer a 7 day course of 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.
  • Refer, or seek specialist advice, if:
    • Treatment failure is unexplained.
    • Treatment fails again.
    • The woman develops systemic symptoms.
    • The diagnosis is unclear.
Basis for recommendation
  • These recommendations are pragmatic advice. There are no published guidelines for women with vulvovaginal candidiasis who are immunocompromised and experience treatment failure.
  • Laboratory tests:
  • 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].
  • Topical nystatin:
    • There is evidence that topical nystatin is effective for treating uncomplicated vulvovaginal candidiasis. It was not normally recommended for vulvovaginal candidiasis, as it is given as a 14-day intravaginal regimen and may stain clothes yellow [FFPRHC and BASHH, 2006].
    • It was recommended for treating infections with non-albicans Candida species because experts believe (on the basis of laboratory evidence) that it is more effective than topical or oral azoles against Candida glabrata and other non-albicans Candida species [BASHH, 2002; FFPRHC and BASHH, 2006]. However, nystatin intravaginal cream is no longer available in the UK.
  • 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:
    • 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.

© NHS Institute for Innovation and Improvement