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Candida - female genital - Management
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Definition
- Recurrent vulvovaginal candidiasis is defined (for research purposes) as the occurrence of four or more episodes within a year.
- In decisions about investigation, treatment, and referral, clinical judgement should be used when classifying a woman as having recurrent vulvovaginal candidiasis.
How do I manage recurrent vulvovaginal candidiasis infection?
- 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.
- 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.
In depth
When should I treat the sexual partner of a woman with vulvovaginal candidiasis?
- Treat the sexual partner only if they are symptomatic.
In depth
What advice can I give about self-management of future episodes?
- If a similar episode occurs in the future, oral and topical treatments can be bought at pharmacies, and no prescription will be required.
- Over-the-counter products should not be used over the longer term without medical advice.
- To return for assessment by a healthcare professional if the woman:
- Is under 16 or over 60 years of age.
- Is pregnant.
- Has symptoms that are not entirely consistent with a previous episode.
- 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.
In depth
Prescriptions
Induction therapy
Age from 12 years onwards
Fluconazole 150mg x3 doses
Fluconazole 150mg capsules
Take one capsule every 3 days for 9 days
Supply 3 capsules.
Itraconazole 200mg x7 days
Itraconazole 100mg capsules
Take two capsules once a day for 7 days.
Supply 14 capsules.
Age from 16 years onwards
Clotrimazole 200mg pessaries x6 nights
Clotrimazole 200mg pessaries
Insert one pessary into the vagina each night for 6 nights.
Supply 6 pessaries.
Clotrimazole 200mg pessaries x12 nights
Clotrimazole 200mg pessaries
Insert one pessary into the vagina each night for 12 nights.
Supply 12 pessaries.
Maintenance therapy (2-month supply)
Age from 12 years onwards
Fluconazole 150mg x2 doses
Fluconazole 150mg capsules
Take one capsule on the same day once a week
Supply 8 capsule.
Age from 16 years onwards
Clotrimazole 500mg pessary x1
Clotrimazole 500mg pessaries
Insert one pessary into the vagina at night once a WEEK.
Supply 8 pessary.
Itraconazole 400mg once a month
Itraconazole 100mg capsules
Take two capsules twice in one day once a MONTH.
Supply 8 capsules.
As required therapy (1-3 days) intravaginal
Age from 16 years onwards
Clotrimazole pessaries 200mg at night x3 nights
Clotrimazole 200mg pessaries
Insert one pessary into the vagina each night for 3 nights.
Supply 3 Pessary.
Clotrimazole 500mg pessary x1
Clotrimazole 500mg pessaries
Insert one pessary into the vagina at night.
Supply 1 Pessary.
Clotrimazole 10% vaginal cream x1 night
Clotrimazole 10% vaginal cream
Insert one 5g applicatorful into the vagina at night as a single dose.
Supply 5 grams.
Econazole 150mg pessaries x3 nights
Ecostatin 150mg pessaries
Insert one pessary into the vagina each night for 3 nights.
Supply 3 Pessary.
Econazole 150mg pessary x3 nights
Gyno-Pevaryl 150mg vaginal pessaries
Insert one pessary into the vagina each night for 3 nights.
Supply 3 pessary.
Econazole 150mg pessary x1 night.
Gyno-Pevaryl 1 vaginal pessaries 150mg
Insert one pessary into the vagina at night.
Supply 1 pessary.
Miconazole 1.2g vaginal ovule x1 night
Miconazole 1200mg vaginal capsules
Insert one ovule into the vagina at night.
Supply 1 Ovule.
As required oral therapy (1 day)
Age from 12 years to 15 years 11 months
Fluconazole 150mg capsules
Take the capsule as a single dose.
Supply 1 capsule.
Age from 12 years onwards
Itraconazole 100mg capsules
Take two capsules twice a day for 1 day only.
Supply 4 capsules.
Age from 16 years onwards
Fluconazole 150mg capsules
Take the capsule as a single dose.
Supply 1 capsule.
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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