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Candida - female genital - Management
View full scenario
How should I manage vulvovaginal candidiasis in women who have poorly controlled diabetes or who are immunocompromised?
- 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 patient 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.
In depth
How should I manage treatment failure in women who have poorly controlled diabetes or who are immunocompromised?
- Check that treatments have been used as recommended.
- Review the clinical evidence on which vulvovaginal candidiasis was diagnosed.
- Consider alternative diagnoses.
- Reassess for other predisposing risk factors, and remove or control as far as possible.
- Send a vaginal specimen for culture.
- Manage:
- Give general advice about avoiding local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
- If compliance has been a problem with an intravaginal imidazole, prescribe a course (7 days) of an oral antifungal (e.g. fluconazole or itraconazole).
- If 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 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.
In depth
Prescriptions
Intravaginal antifungals (6-14 days)/diabetes
Age from 16 years onwards
Clotrimazole 100mg pessaries x6 nights
Clotrimazole 100mg pessaries
Insert one pessary into the vagina each night for 6 nights.
Supply 6 pessary.
Clotrimazole 200mg pessaries x6 nights
Clotrimazole 200mg pessaries
Insert one pessary into the vagina each night for 6 nights.
Supply 6 pessaries.
Clotrimazole 100mg pessaries x12 nights
Clotrimazole 100mg pessaries
Insert one pessary into the vagina each night for 12 nights.
Supply 12 pessary.
Econazole 150mg pessaries x6 nights
Econazole 150mg pessaries
Insert one pessary into the vagina each night for 6 nights.
Supply 6 pessary.
Intravaginal antifungals (7-14 days)/combipacks/diabetes
Age from 12 years onwards
Miconazole 2% vaginal cream x 7nights
Miconazole 2% cream
Insert one 5g applicatorful into the vagina twice a day for 7 days, and apply cream to the outer affected area twice a day for 7 days.
Supply 1 combi pack.
Age from 16 years onwards
Miconazole 2% vaginal cream x14 nights
Miconazole 2% cream
Insert one 5g applicatorful into the vagina each night for 14 nights, and apply cream to the outer affected area each night for 14 nights.
Supply 1 combi pack.
Oral antifungals (7 days)/diabetes
Age from 12 years onwards
Fluconazole 100mg x7 days
Fluconazole 50mg capsules
Take two capsules once a day for 7 days.
Supply 14 capsules.
Itraconazole 200mg x7 days
Itraconazole 100mg capsules
Take two capsules once a day for 7 days.
Supply 14 capsules.
External cream (add on treatment)
Age from 12 years onwards
Clotrimazole cream 2% apply 2 to 3 times a day
Clotrimazole 2% cream
Apply to the affected area 2 to 3 times a day for up to 7 days
Supply 20 grams.
Econazole 1% cream apply twice a day
Econazole 1% cream
Apply to the affected area twice a day for up to 7 days.
Supply 30 grams.
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