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Candida - female genital - Management
How should I treat uncomplicated vulvovaginal candidiasis?

  • Give general advice to avoid local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
  • Prescribe (or recommend over-the-counter purchase of) a short course (1–3 days) of an intravaginal antifungal (e.g. clotrimazole, econazole, or miconazole) or oral antifungal (e.g. fluconazole or itraconazole).
    • Choice of route and formulation depends upon a number of factors, including the woman's preference.
    • For girls aged between 12 and 16 years, oral antifungals (itraconazole or fluconazole) 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.
  • For vulval symptoms, consider using a topical imidazole cream (e.g. clotrimazole, or econazole) in addition to the oral or intravaginal antifungal.
  • Advise the woman to return if symptoms have not resolved within 7–14 days.
  • Follow-up and test of cure is not necessary if symptoms resolve.
Basis for recommendation
  • These recommendations are based on published expert opinion from the medical literature, systematic reviews, and randomized controlled trials (RCTs) [CDC, 2006; RCGP and BASHH, 2006; Spence, 2006].
  • Recommended treatments:
    • There is evidence that intravaginal clotrimazole, econazole, and miconazole, as well as oral itraconazole, are all effective against acute uncomplicated vulvovaginal candidiasis. Vaginal and oral azole treatments give clinical cure rates of about 75% and laboratory cure rates of about 80% for acute vulvovaginal candidiasis.
    • Evidence from RCTs shows oral triazoles (fluconazole and itraconazole) to be as effective as vaginal imidazoles for the treatment of vulvovaginal candidiasis. However, there is evidence that time to relief is shorter with topical treatments than with oral treatments.
    • Vulval application of imidazoles for women with vulval symptoms is recommended as good practice by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC and BASHH, 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].
    • Oral itraconazole is licensed for use in girls over 12 years old.
    • Oral fluconazole is not licensed for use in children less than 16 years old, however experts suggest that it may be an appropriate option for girls between the ages of 12 and 16 years [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.
  • 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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