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Candida - female genital - Management
How should I manage treatment failure of severe vulvovaginal candidiasis?

  • Review:
    • A wrong diagnosis is a common cause for treatment failure, therefore, consider alternative diagnoses.
    • Reassess for 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 (if feasible).
      • 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 (two doses 3 days apart) of oral fluconazole 150 mg.
    • If non-compliance has been a problem with oral fluconazole, prescribe clotrimazole pessaries 500 mg (2 doses 3 days apart).
    • For vulval symptoms, consider prescribing a topical imidazole cream in addition to an oral or intravaginal antifungal.
    • For girls aged between 12 and 16 years, offer oral fluconazole.
      • In this age group oral antifungals are generally preferred over intravaginal treatments. However, intravaginal antifungals may be considered if the girl is sexually active, if she uses tampons, or if there is no other alternative.
  • Refer, or seek specialist advice, if:
    • Symptoms have not improved and treatment failure is unexplained.
    • Treatment fails again.
Basis for recommendation
  • These recommendations are pragmatic advice. CKS found no evidence or national guidelines specifically on treatment failure of severe vulvovaginal candidiasis.
  • Girls aged 12–16 years:
  • 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.
  • Other treatments:
    • Oral ketoconazole is not normally recommended for the management of severe 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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