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 To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?'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 treat severe vulvovaginal candidiasis?

  • Give general advice to avoid local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
  • Investigate:
    • Send a vaginal specimen for microscopy and culture to confirm the diagnosis. This may identify:
      • 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.
  • Treat:
    • Treat with either two doses of oral fluconazole (150 mg) 3 days apart, or, if oral treatment is contraindicated, use 2 clotrimazole pessaries (500 mg) 3 days apart.
    • Choice of antifungal will depend upon a number of factors, including the woman's preference.
    • For girls aged between 12 and 16 years, an oral antifungal (fluconazole) is 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.
    • For vulval symptoms, consider using a topical antifungal cream (e.g. clotrimazole or econazole) in addition to an oral or intravaginal antifungal.
  • Advise the woman to return if symptoms have not resolved within 7–14 days.
Basis for recommendation
  • These recommendations are based on published expert opinion and one randomized controlled trial (RCT). Longer courses of antifungals are recommended because short courses of topical or oral therapy have lower clinical response rates [CDC, 2006].
  • Oral antifungals:
    • One RCT (n = 398) found that women with severe vulvovaginal candidiasis achieved superior clinical and mycologic eradication with two sequential 150 mg doses of fluconazole 150 mg given 3 days apart, compared with a single dose of fluconazole [Sobel et al, 2001].
    • CKS did not find any evidence that extended courses of oral itraconazole were effective for severe vulvovaginal candidiasis.
  • Topical imidazoles given for 6–14 days:
    • CKS did not find any evidence that extended courses of intravaginal imidazoles improved cure rates for severe vulvovaginal candidiasis. However they are widely recommended [CDC, 2006]. The dose of clotrimazole is one recommended by the British Association for Sexual Health and HIV (BASHH).
  • Girls aged 12–16 years:
  • 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.
  • 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 severe 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.

© NHS Institute for Innovation and Improvement