• Scenario: Uncomplicated infection: covers the management of women presenting with an uncomplicated isolated episode of vulvovaginal candidiasis, and how to manage treatment failure. Uncomplicated vulvovaginal candidiasis is defined as:
• Sporadic or infrequent, and
• Mild to moderate, and
• Likely to be due to Candida albicans, and
• NOT associated with risk factors such as pregnancy, poorly controlled diabetes, compromised immunity, and debilitation.
• Scenario: Severe infection: covers the management of women presenting with severe vulvovaginal candidiasis (i.e. with extensive vulvar erythema, oedema, excoriation, and fissure formation), and how to manage treatment failure.
• Scenario: Recurrent infection: covers the management of women suffering from recurrent vulvovaginal candidiasis (i.e. four or more episodes in a year).
• Scenario: During pregnancy: covers the management of women who are pregnant and have vulvovaginal candidiasis, and how to manage treatment failure.
• Scenario: Diabetes or immunocompromised: covers the management of vulvovaginal candidiasis in women who have poorly controlled diabetes mellitus, or who are immunocompromised.

• 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.

• 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

• 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

• 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

• Treat the sexual partner only if they are symptomatic.

In depth

• In severe vulvovaginal candidiasis there is:
• Extensive vulvar erythema
• Oedema
• Excoriation
• Fissure formation

• Send a vaginal specimen for microscopy and culture.
• Treat:
• Treat with either two doses of oral fluconazole (150 mg) 3 days apart, or, if oral treatment is contraindicated, use two 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.

In depth

• Consider alternative diagnoses — a 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 culture.
• Manage:
• If non-compliance has been a problem with an intravaginal imidazole, prescribe a course of oral fluconazole 150 mg (2 doses 3 days apart).
• 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.

In depth

• 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

• Treat the sexual partner only if they are symptomatic.

In depth

• 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.

• 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

• Treat the sexual partner only if they are symptomatic.

In depth

• 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

• Vulvovaginal candidiasis is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection, usually a Candida species.
• Vulvovaginal candidiasis during pregnancy is considered to be complicated vulvovaginal candidiasis, because it requires more intensive treatment than uncomplicated vulvovaginal candidiasis.

• Treat 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 physical damage to 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.

In depth

• 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.
• 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 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.

In depth

• Treat the sexual partner only if they are symptomatic.

In depth

• 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

• 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