• Assess symptoms to ensure they are consistent with vulvovaginal candidiasis.
• Enquire into any previous episodes. Is this an isolated episode, a recurrence, or treatment failure?
• Ask about any treatments that have been tried already (over-the-counter or prescribed).
• Assess severity — in severe inflammation there is extensive vulvar erythema, oedema, excoriation, and fissure formation.

• These recommendations are based on expert opinion in guidelines [CDC, 2006; BASHH, 2006; FFPRHC and BASHH, 2006; RCGP and BASHH, 2006].

• Enquire into the presence of risk factors for vulvovaginal candidiasis, such as recent use of antibiotics, pregnancy, diabetes mellitus, and immunocompromised status.
• Consider testing for risk factors.

• Diabetes mellitus:
• Screen the urine for glucose in women with recurrent or complicated vulvovaginal candidiasis.
• Consider a fasting glucose test for postmenopausal women and for women with symptoms suggestive of diabetes mellitus. For more information see the CKS topic on Diabetes type 2.
• HIV:
• Do not test for HIV in women with vulvovaginal candidiasis (uncomplicated, complicated, or recurrent) unless there are other features suggestive of immunosuppression and high risk for HIV.
• Hormonal contraceptives:
• Do not advise stopping hormonal contraceptives, even in women with severe or recurrent vulvovaginal candidiasis.

• The evidence on risk factors is summarized in the section Risk factors.
• These recommendations are mainly based on expert opinion because CKS found no relevant clinical trials.
• Diabetes mellitus:
• Two guidelines recommend excluding diabetes mellitus in women with recurrent vulvovaginal candidiasis [BASHH, 2002; FFPRHC and BASHH, 2006].
• An American expert has recommended doing a glucose-tolerance test for postmenopausal women because they rarely have vulvovaginal candidiasis without an underlying risk factor. The risk (prior probability) of diabetes in this group was not estimated [Sobel, 2003; Sobel, 2007].
• CKS therefore recommends testing the urine for glucose in women with severe or recurrent vulvovaginal candidiasis, and considering a glucose-tolerance test for postmenopausal women with vulvovaginal candidiasis.
• HIV:
• One expert recommends that only women with recurrent vulvovaginal candidosis who have risk factors for HIV infection should be tested for HIV [Sobel, 2007]. The reasoning is that:
• Up to 8% of women who are HIV negative have recurrent vulvovaginal candidosis.
• Most women who have vulvovaginal candidosis are HIV negative.
• The benefits of screening women in this group for HIV are doubtful and have not been studied.
• One study of women with HIV/AIDS found that oral candidiasis was more frequent than vulvovaginal candidiasis [Ohmit et al, 2003].
• Vulvovaginal candidiasis is no more severe in women with HIV than those without [Duerr et al, 2003].
• CKS therefore recommends that otherwise healthy women should not be tested for HIV.
• Hormonal contraceptives:
• One expert states that there is no good evidence that hormonal contraceptives increase the risk of vulvovaginal candidiasis, and thus there is no reason to stop them, even in women with recurrent vulvovaginal candidiasis [Sobel, 2003; Sobel, 2007].

When appropriate:

• Reassure the woman that vulvovaginal candidiasis is not a sexually transmitted infection (STI). Her partner will therefore not need to be told, tested, or treated (unless they also have genital symptoms).
• Advise the woman to consider screening for STIs if she is concerned or if she has any of the following risk factors:
• Misuse of alcohol or 'recreational' drugs.
• Early age of onset of sexual activity.
• Sexual activity without use of condoms.
• Frequent change of, or multiple, sexual partners.
• Known contact of a sexually transmitted infection.

• These recommendations follow guidelines published by the National Institute for Health and Clinical Excellence [NICE, 2007].

• 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.

• 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.

• Review:
• Check that treatments have been used as recommended.
• Topical azole therapies can cause vulvovaginal irritation, so consider this if symptoms persist or worsen.
• 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 microscopy and culture to identify:
• 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.
• Treat:
• 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 short course of an oral antifungal (e.g. fluconazole or itraconazole) as compliance is likely to be higher.
• If symptoms are improving, consider treating with a longer course of an oral antifungal (e.g. itraconazole or fluconazole) or an intravaginal antifungal (e.g. clotrimazole, econazole, or miconazole).
• 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 prescribing a topical imidazole (e.g. clotrimazole or econazole) cream in addition to an oral or intravaginal antifungal.
• Refer, or seek specialist advice, if:
• Symptoms are not improving and treatment failure is unexplained.
• Treatment fails again.
• If diagnosis is unclear.

• CKS found no evidence or national guidelines specifically on treatment failure of uncomplicated vulvovaginal candidiasis, which usually responds well to treatment.
• Review, investigation, referral:
• These recommendations are pragmatic advice.
• Guidelines recommend sending a vaginal swab for fungal microscopy and culture [BASHH, 2002; CDC, 2006; BASHH, 2006; FFPRHC and BASHH, 2006; HPA, 2007; RCGP and BASHH, 2006].
• Treatment:
• The doses CKS has recommended for extended courses are estimates only, as published reviews and guidelines do not give details of what doses to use. Where possible CKS has recommended preparations that are licensed for extended use.
• Intravaginal nystatin was recommended for 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. The Centers for Disease Control recommend using any azole antifungal except fluconazole (but do not cite any supporting evidence) [CDC, 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 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.

• 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.

• 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:
• For girls aged between 12 and 16 years CKS recommends oral fluconazole because there is evidence that it is effective for severe vulvovaginal candidiasis [Sobel et al, 2001]. Also, experts suggest that, in this age group, oral treatments are more appropriate than intravaginal treatments [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.
• 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.

• 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.

• 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:
• For girls aged between 12 and 16 years CKS recommends oral fluconazole because there is evidence that it is effective for severe vulvovaginal candidiasis [Sobel et al, 2001]. Also, experts suggest that, in this age group, oral treatments are more appropriate than intravaginal treatments [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.
• 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.

• 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).
• See the CKS topics on Bacterial vaginosis and Trichomoniasis.
• 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.

• 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.

• 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.

• For women who have poorly controlled diabetes or who are are immunocompromised (e.g. receiving immunosuppressant drugs such as long-term corticosteroids, or with HIV/AIDS):
• Correct modifiable conditions (e.g. uncontrolled diabetes).
• Give general advice to avoid local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
• Treat with long courses (7 days) of oral antifungals (e.g. fluconazole or itraconazole), or intravaginal antifungals (e.g. clotrimazole, econazole, or miconazole) for 6–14 days.
• Choice of treatment will depend upon a number of factors, including the woman's preference.
• For vulval symptoms, consider using a topical imidazole cream (e.g. clotrimazole, or econazole), in addition to an oral or intravaginal antifungal.
• For girls aged between 12 and 16 years, offer a 7 day course of an 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.
• Advise the woman to return if:
• Symptoms have not resolved within 7–14 days.
• She becomes systemically unwell.

• Treatment of vulvovaginal candidiasis in HIV-infected women who are not immunocompromised is the same as that for HIV–negative women.
• Treatment of women with well-controlled diabetes is the same as that for women without diabetes.

• These recommendations are based on expert opinion published in the medical literature [CDC, 2006].
• Women with underlying debilitating medical conditions such as uncontrolled diabetes, or those receiving immunosuppressive drugs (e.g. corticosteroid treatment), do not respond as well to short-term therapies [CDC, 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].
• 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:
• 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.

• 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.

• These recommendations are pragmatic advice. There are no published guidelines for women with vulvovaginal candidiasis who are immunocompromised and experience treatment failure.
• Laboratory tests:
• Guidelines recommend sending vaginal swab for fungal microscopy and culture [CDC, 2006; BASHH, 2006; FFPRHC and BASHH, 2006; HPA, 2007; RCGP 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].
• 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.

• Treat symptomatic women with intravaginal clotrimazole or miconazole for at least 7 days.
• Advise the woman that care should be taken when using an applicator during pregnancy to avoid injuring the cervix. Some women prefer to insert pessaries by hand when pregnant.
• For vulval symptoms, consider using a topical imidazole cream (e.g. clotrimazole), in addition to an intravaginal imidazole.
• Do not use oral antifungals such as fluconazole and itraconazole.
• Advise the woman to return if:
• Symptoms have not resolved within 7–14 days.
• Refer to a genito-urinary medicine clinic if sexually transmitted infection is suspected.

• These recommendations are based on published expert opinion from the medical literature and a systematic review [Young and Jewell, 2001; CDC, 2006; FFPRHC and BASHH, 2006].
• There is evidence that treatment with topical imidazoles are more effective than topical nystatin in the treatment of pregnant women with vulvovaginal candidiasis, and that longer courses (7 days) cured more than 90% of women whereas standard (4-day) courses only cured about half the cases [Young and Jewell, 2001].
• Safety:
• Oral triazoles (fluconazole and itraconazole) are contraindicated in pregnant women.
• Animal studies have found that high doses of itraconazole cause fetal abnormalities, and there are concerns that fluconazole may cause congenital defects [Weiner and Buhimschi, 2004].
• Topical imidazoles (clotrimazole or miconazole) are safe to use in pregnant women.
• Systemic absorption of clotrimazole and miconazole is minimal [Micromedex, 2010].
• The available data suggest that there is no evidence of an increased risk of spontaneous abortions or malformations with clotrimazole compared with the background rate [NTIS, 2008].
• There are fewer data on exposure to miconazole during pregnancy, but the available data do not indicate an increased risk [Schaefer et al, 2007; Micromedex, 2010].
• However, the manufacturer of econazole has recently updated the Summary of Product Characteristics to state that it is not recommended in pregnancy [ABPI Medicines Compendium, 2010]. In animals studies, econazole was not shown to be teratogenic, but was foetotoxic. The significance of this effect in humans is unknown.
• Girls between 12 and 16 years old:
• Intravaginal treatments are generally not recommended for girls between 12 and 16 years old unless, as in this situation, they are sexually active, or there is no other alternative [BNF for Children, 2007].

• 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 symptoms are improving, consider giving a second course of an intravaginal antifungal (clotrimazole or miconazole).
• Do not use oral antifungals such as fluconazole or ketoconazole.
• For vulval symptoms, consider prescribing a topical imidazole cream (e.g. clotrimazole) in addition to an intravaginal imidazole.
• Refer, or seek specialist advice if:
• Compliance has been a problem because of adverse effects.
• Symptoms are not improving and treatment failure is unexplained.
• The diagnosis is unclear.

• These recommendations are pragmatic advice. CKS found no evidence or national guidelines specifically on treatment failure of vulvovaginal candidiasis in pregnancy.
• Review, investigation, referral:
• These recommendations are pragmatic advice.
• Guidelines recommend sending vaginal swab for fungal microscopy and culture [BASHH, 2002; CDC, 2006; BASHH, 2006; FFPRHC and BASHH, 2006; HPA, 2007; RCGP and BASHH, 2006].
• Treatment:
• The doses CKS has recommended for extended courses are estimates only, as published reviews and guidelines do not give details of what doses to use. Where possible CKS has recommended preparations that are licensed for extended use.
• Intravaginal nystatin was recommended for 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. The Centers for Disease Control recommend using any azole antifungal except fluconazole (but do not cite any supporting evidence) [CDC, 2006].
• Safety:
• Oral triazoles (fluconazole and itraconazole) are contraindicated in pregnant women.
• Animal studies have found that high doses of itraconazole cause fetal abnormalities, and there are concerns that fluconazole may cause congenital defects [Weiner and Buhimschi, 2004].
• Topical imidazoles (clotrimazole, econazole or miconazole) are safe to use in pregnant women.
• Systemic absorption of clotrimazole and miconazole is minimal [Micromedex, 2010].
• The available data suggest that there is no evidence of an increased risk of spontaneous abortions or malformations with clotrimazole compared with the background rate [NTIS, 2008].
• There are fewer data on exposure to miconazole during pregnancy, but the available data do not indicate an increased risk [Schaefer et al, 2007; Micromedex, 2010].
• However, the manufacturer of econazole has recently updated the Summary of Product Characteristics to state that it is not recommended in pregnancy [ABPI Medicines Compendium, 2010]. In animal studies, econazole was not shown to be teratogenic, but was foetotoxic. The significance of this effect in humans is unknown.
• Girls between 12 and 16 years old:
• Intravaginal treatments are generally not recommended for girls between 12 and 16 years old unless, as in this situation, they are sexually active, or there is no other alternative [BNF for Children, 2007].

• Treat the sexual partner only if they are symptomatic.

• Rarely, the male partner of a woman with vulvovaginal candidiasis has symptoms of balanitis, and this should be treated with a topical or oral antifungal. See the CKS topic on Balanitis for more detailed information.
• There is no need to investigate or treat an asymptomatic partner.

• There is some evidence that treating an asymptomatic male partner is of little or no benefit in reducing the woman's risk of reinfection/recurrence.
• Guidelines recommend that asymptomatic male partners not be treated [BASHH, 2002; CDC, 2006; FFPRHC and BASHH, 2006].

• Avoid local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
• Probiotics (e.g. live yoghurts) may be used orally or topically. Although there is no evidence that they are effective, there is no evidence of (or concern about) adverse effects.
• Return for review if symptoms have not resolved within 7–14 days.

• This advice is generally based on expert opinion [Watson and Bond, 2003; CDC, 2006; Sobel, 2007].
• Local irritants (soaps and shower gels) and tight-fitting synthetic clothes:
• There is limited evidence that tight-fitting clothes are a risk factor for vulvovaginal candidiasis and CKS found no evidence that local irritants such as soaps and shower gels increase the risk of vulvovaginal candidiasis. However, avoiding local irritants and tight-fitting synthetic clothes are widely recommended practices [BASHH, 2002; FFPRHC and BASHH, 2006].
• Probiotics:
• Although there is no good evidence of effectiveness in treating or preventing acute or recurrent vulvovaginal candidiasis, there is no evidence of (or concern about) harm.

• Advise the woman that:
• If she suffers from a similar episode in the future, she can buy oral and topical treatments at pharmacies, and no prescription will be required.
• Self-diagnosing can be unreliable and over-the-counter products should not be used over the longer term without medical advice.
• She should return for assessment by a healthcare professional if she:
• Is under 16 or over 60 years of age.
• Is pregnant.
• Has abnormal menstrual bleeding or lower abdominal pain.
• Develops systemic symptoms.
• Has symptoms that are not entirely consistent with a previous episode (e.g. discharge is coloured or malodorous, there are ulcers or blisters).
• Has symptoms that do not settle after use of over-the-counter products.
• Has had two episodes in 6 months, and has not consulted a healthcare professional about the condition for more than a year.
• Has had a previous sexually transmitted infection (herself or her partner).
• Has had a previous adverse reaction to an antifungal drug; or antifungal drugs have proved ineffective.

• This advice is based upon expert opinion from the published medical literature [Nyirjesy, 2001; Watson and Bond, 2003; CDC, 2006; Sobel, 2007].
• Self diagnosis:
• Up to two-thirds of women who have self-diagnosed uncomplicated candidiasis do not actually have the condition [Nyirjesy et al, 1997; Ferris et al, 2002].
• Over-the-counter preparations:
• Guidelines state that unnecessary or inappropriate use of over-the-counter preparations can lead to a delay in the treatment of other vulvovaginal conditions [CDC, 2006].