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Candida - female genital - Management
How do I manage recurrent vulvovaginal candidiasis infection?
- Eliminate or control predisposing risk factors as far as is practical.
- Take a high vaginal swab for microscopy and speciated culture to confirm the diagnosis, and identify the presence of:
- Non-albicans Candida species (although a rare cause of chronic disease), which may be resistant to azole antifungals.
- A mixed infection such as candidiasis with bacterial vaginosis or trichomoniasis (up to 10% of infections are mixed).
- Consider alternative diagnoses if a woman has recurrent or persistent symptoms.
- Treat the presenting episode:
- With a longer induction course. Two options are:
- Fluconazole 150 mg every 72 hours for 3 doses, or
- Topical imidazole therapy for 10–14 days according to symptomatic response.
- Seek specialist advice for the treatment of recurrent non-albicans Candida species infections.
- For vulval symptoms, consider using a topical antifungal cream, in addition to the oral or intravaginal antifungal.
- For future management offer:
- Either 'treatment as required', with a prescription to be used if symptoms recur,
- Or a 'maintenance regimen' with 6 months of an oral or intravaginal antifungal (off licence use).
- Follow up after the maintenance period has been completed.
- If, after completing a course of maintenance therapy, vulvovaginal candidiasis recurs infrequently, treat each episode independently. If recurrent disease is troublesome, repeat the induction and maintenance regimens.
- Choice of antifungal regimen:
- The choice of antifungal and route (oral or intravaginal) will depend upon a number of factors. Most women prefer oral products to intravaginal creams or pessaries, especially for longer-term use.
- For girls between 12 and 16 years old, offer oral fluconazole or itraconazole (off license uses) for induction, maintenance or 'treatment as required'.
- However, intravaginal antifungals may be considered if the girl is sexually active, if tampons are being used, or if there is no other alternative.
Clarification / Additional information
- Options for induction therapies:
- Intravaginal clotrimazole 200 mg once a day, for 10–14 days.
- Oral fluconazole 150 mg once every 3 days, for three doses.
- Oral itraconazole 200 mg once a day, for 7 days.
- Options for maintenance therapies (6 months):
- Intravaginal clotrimazole 500 mg once a week.
- Oral fluconazole 150 mg once a week.
- Oral itraconazole 200 mg twice a day for 1 day, once a month.
Basis for recommendation
- Obtaining fungal cultures from vaginal secretions:
- Vaginal cultures should be obtained to confirm the clinical diagnosis and to identify unusual species, including non-albicans Candida species, because:
- Candida glabrata and other non-albicans Candida species are observed in 10–20% of women with recurrent vulvovaginal candidiasis [CDC, 2006].
- Conventional antimycotic therapies are not as effective against these species [CDC, 2006].
- Maintenance treatment:
- There is evidence from randomized controlled trials (RCTs) that maintenance therapy with weekly oral fluconazole, monthly oral itraconazole, or monthly intravaginal clotrimazole reduces rates of recurrence of vulvovaginal candidiasis. Recurrence rates increase when maintenance treatment is stopped, but in one trial important clinical benefits remained for at least 6 months for women who had used oral fluconazole.
- CKS recommends intravaginal clotrimazole, oral fluconazole, and oral itraconazole for maintenance treatment, as these have been assessed in clinical trials and are recommended in published guidelines [BASHH, 2002; CDC, 2006; FFPRHC and BASHH, 2006; RCGP and BASHH, 2006].
- One small observational study reported that women preferred oral to intravaginal treatments for recurrent candidiasis [Kovacs et al, 1990].
- Empiric self-treatment:
- One small crossover RCT (23 participants) provides weak evidence that a majority of women might prefer self-treatment, although regular maintenance therapy is more effective [Fong, 1994].
- Oral antifungal treatments for girls between 12 and 16 years old:
- Intravaginal antifungals should generally be avoided in girls aged between 12 and 16 years [BNF for Children, 2007].
- Oral itraconazole is licensed for use in girls over 12 years old, but only for a 1 day course.
- Oral fluconazole is not licensed for use in children less than 16 years old.
- However, experts suggest that oral antifungals may be more appropriate than intravaginal treatments for girls between the ages of 12 and 16 years [BNF for Children, 2007; Daniels, Personal Communication, 2007].
- Adverse effects:
- There is evidence from a number of RCTs 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.
- Other treatments:
- Topical nystatin. There is evidence that topical nystatin is effective for treating uncomplicated vulvovaginal candidiasis. It is 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 is 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].
- Oral ketoconazole is not normally recommended for the management of recurrent vulvovaginal candidiasis. 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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