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Candida - female genital - Management
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Definition
- Uncomplicated vulvovaginal candidiasis is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection, usually a Candida species. Such infections are:
- Sporadic or infrequent, and
- Mild-to-moderate, and
- Likely to be due to Candida albicans, and
- In women who are not pregnant, diabetic, immunocompromised, or debilitated.
How should I treat uncomplicated vulvovaginal candidiasis?
- 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.
In depth
How should I manage treatment failure in uncomplicated vulvovaginal candidiasis?
- Check that treatments have been used as recommended.
- Topical azole therapies can cause vulvovaginal irritation, so consider this if symptoms persist or worsen.
- Consider alternative diagnoses — wrong diagnosis is a common cause for treatment failure.
- Reassess for predisposing risk factors, and remove or control as far as possible.
- Send a vaginal specimen for microscopy and culture.
- Treat:
- If non-compliance has been a problem with an intravaginal imidazole, prescribe a short course of an oral antifungal (e.g. fluconazole or itraconazole).
- If symptoms are improving, consider treating with a longer course of an oral (e.g. itraconazole or fluconazole) or an intravaginal (e.g. clotrimazole, econazole, or miconazole) antifungal.
- 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.
In depth
What general advice can I give about self-management of the current infection?
- 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.
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
Prescriptions
1st line intravaginal antifungals (1-3 days)
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.
1st line intravaginal combipacks (1-3 days)
Age from 16 years onwards
Econazole 150mg pessaries (x3 nights) + 1% cream
Ecostatin Twin Pack
Insert one pessary high into the vagina each night for 3 nights, and apply cream to the outer affected area twice a day for 3 days.
Supply 1 Twin pack.
Clotrimazole 500mg pessary (x1 night) + 2% cream
Clotrimazole 500mg pessary and Clotrimazole 2% cream
Insert one pessary into the vagina at night for 1 night, and apply cream to the outer affected area 2 to 3 times a day for up to 7 days.
Supply 1 combi-pack.
1st line 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.
Treatment failure-intravaginal antifungals (6-14 days)
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 100mg pessaries x12 nights
Clotrimazole 100mg pessaries
Insert one pessary into the vagina each night for 12 nights.
Supply 12 pessary.
Clotrimazole 200mg pessaries x6 nights
Clotrimazole 200mg pessaries
Insert one pessary into the vagina each night for 6 nights.
Supply 6 pessaries.
Econazole 150mg pessaries x6 nights
Econazole 150mg pessaries
Insert one pessary into the vagina each night for 6 nights.
Supply 6 pessary.
Treatment failure-intravaginal combipacks (7-14 days)
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.
Treatment failure-oral therapy (7 days)
Age from 12 years onwards
Itraconazole 200mg x7 days
Itraconazole 100mg capsules
Take two capsules once a day for 7 days.
Supply 14 capsules.
Age from 16 years onwards
Fluconazole capsules: 100mg once a day for 7 days
Fluconazole 50mg 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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