g logo ipb green

The 2007 United Kingdom national guideline on the management of vulvovaginal candidiasis

  • Vulvovaginal candidiasis may be caused by Candida albicans (80–92%) or non-albicans species of yeast such as C. glabrata. The symptoms caused by the different species are indistinguishable


Clinical features

  • Symptoms:
    • vulval itching
    • vulval soreness
    • vaginal discharge
    • external dysuria
    • superficial dyspareunia
  • Signs:
    • erythema
    • fissuring
    • oedema
    • satellite lesions
    • discharge
      • typically, but not always curdy
      • not associated with malodour
    • excoriation
  • None of these symptoms or signs is specific for the diagnosis of candidiasis
    • up to half of self-diagnosed women may have other conditions, e.g. allergic reactions, lichen sclerosus, dermatitis
    • 10–20% of reproductive-age women may harbour Candida species in the absence of symptoms and do not require treatment


  • Recommendations about investigations from the full BASHH guideline are more appropriate for a secondary care setting. For a primary care setting, please refer to the 2012 FSRH guideline on the Management of Vaginal Discharge in Non-Genitourinary Medicine Settings, which states that microscopy and culture are not routinely carried out on women with features of typical acute uncomplicated vulvovaginal candidiasis


  • All patients should be advised to:
    • avoid local irritants, e.g. perfumed products, and tight-fitting synthetic clothing
    • use soap substitutes (refer to the 2012 FSRH guideline on the Management of Vaginal Discharge in Non-Genitourinary Medicine Settings)

Treatment of uncomplicated vulvovaginal candidiasis

  • All topical and oral azole therapies give a clinical and mycological cure rate of >80% in uncomplicated acute vulvovaginal candidiasis. Thus choice is a matter of personal preference, availability and affordability
  • Topical azole therapies can cause vulvovaginal irritation and this should be considered if symptoms worsen or persist
  • Topical therapies
Clotrimazole* Pessary 500 mg stat
Clotrimazole* Pessary 200 mg x 3 nights
Clotrimazole* Pessary 100 mg x 6 nights
Clotrimazole* Vaginal cream (10%) 5 g stat
Econazole** Pessary 150 mg stat
Econazole** Pessary 150 mg x 3 nights
Fenticonazole** Pessary 600 mg stat
Fenticonazole** Pessary 200 mg x 3 nights
Isoconazole* Vaginal tablet 300 mg x 2 stat
Miconazole** Ovule 1.2 g stat
Miconazole** Pessary 100 mg x 14 nights
*Effect on latex condoms and diaphragms not known
**Product damages latex condoms and diaphragms
  • Oral therapies
Fluconazole* Capsule 150 mg stat
Itraconazole* Capsule 200 mg bd x 1 day
*Avoid in pregnancy/risk of pregnancy and breastfeeding
  • Most cases of vulvovaginal candidiasis infections are uncomplicated. It is regarded as complicated in the following circumstances:
    • severe symptoms (a subjective assessment)
    • pregnancy
    • recurrent vulvovaginal candidiasis (more than four attacks per year)
    • non-albicans species
    • abnormal host factors (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression)


  • Asymptomatic colonisation with Candida species is more common (30–40%)
  • Symptomatic candidiasis is more prevalent throughout pregnancy
  • Colonisation with Candida species is not associated with low birth weight or premature delivery
  • Topical imidazoles should be used for symptomatic vulvovaginal candidiasis in pregnancy. There is no evidence that any one topical imidazole is more effective than another. Longer courses are recommended; a 4-day course will cure just over 50% whereas a 7-day course cures over 90%
  • Asymptomatic pregnant women do not need to be treated
  • Oral therapy is contraindicated

Recurrent vulvovaginal candidiasis

  • Defined as four or more documented episodes of symptomatic vulvovaginal candidiasis annually, with at least partial resolution of symptoms between episodes
  • Positive microscopy or a moderate/heavy growth of C. albicans should be documented on at least two occasions when symptomatic
  • Affects approximately 5% of women of reproductive age
  • Caused by host factors rather than a more virulent strain or reintroduction of the organism (usually C. albicans) to the genital tract. Host factors include:
    • persistence of Candida (as detected by PCR although culture-negative between attacks)
    • uncontrolled diabetes mellitus
    • immunosuppression
    • hyperoestrogenaemia (including HRT and the combined oral contraceptive pill)
    • disturbance of vaginal flora (e.g. through use of broad-spectrum antibiotics)
    • link to allergy (in particular allergic rhinitis) and pro-inflammatory genetic markers
  • Further investigations:
    • speciated fungal culture
    • full blood count
    • random blood glucose only if other indicators are present
  • General advice
    • as per uncomplicated disease
    • vulval emollients may give symptomatic relief as both secondary and primary vulval dermatitis is commonly present
      review contraception. Avoid high-oestrogen contraceptives. Low oestrogen pills do not highly predispose to
    • vulvovaginal candidiasis but may possibly have a negative influence on relapsing episodes
    • consider use of depot medroxyprogesterone acetate


  • The principle of therapy involves an induction regimen to ensure clinical remission, followed immediately by a maintenance regimen
  • Approximately 90% of women will remain disease-free at 6 months, and 40% at 1 year

Alternative regimens

  • Induction—topical imidazole therapy can be increased to 10–14 days according to symptomatic response
  • Maintenance
Clotrimazole Pessary 500 mg once a week
Fluconazole* Capsule 50 mg daily
Itraconazole* Capsule 50–100 mg daily
Ketoconazole* Capsule 100 mg daily
*Avoid in pregnancy/risk of pregnancy and breastfeeding
  • Cautions:
    • low risk of idiosyncratic drug-induced hepatitis, particularly with itraconazole and ketoconazole
    • these regimens are unlicensed for this indication
    • anecdotal reports of oral contraceptive failure with prolonged oral azole therapy
  • Maintenance therapy should last 6 months; 90% of women should remain disease-free during treatment
  • If there is a relapse between doses consider twice-weekly 150 mg fluconazole or 50 mg fluconazole daily. Alternatively, consider the addition of cetirizine 10 mg od
  • There are no trials addressing the optimal duration of suppressive therapy. If recurrences after maintenance regimen are infrequent, each episode should be treated independently. If recurrent disease is re-established, the induction and maintenance regimens should be repeated

Alternative treatments


  • Evidence does not support use of oral or vaginal lactobacillus for the prevention of vulvovaginal candidiasis. Adverse effects from their use are extremely infrequent, however, and there are anecdotal reports of benefit. The mode of action might be through the modulation of inflammatory processes rather than due to a competitive effect with Candida


  • There is insufficient evidence to make any dietary recommendations, including those on carbohydrate or yeast intake

Role of allergy

  • Zafirlukast 20 mg bd for 6 months may induce remission. Zafirlukast may be considered as maintenance prophylaxis for recurrent vulvovaginal candidiasis, particularly in women with a history of atopy. Cetirizine 10 mg daily for 6 months may cause remission in women who fail to get complete resolution of symptoms with suppressive fluconazole

Tea tree oil (and other essential oils)

  • These are antifungal in vitro but may cause hypersensitivity reactions. There is insufficient evidence to recommend their use in recurrent vulvovaginal candidiasis

Severe vulvovaginal candidiasis

  • Regardless of a history of recurrence, fluconazole 150 mg should be repeated after 3 days as this improves symptomatic response but not recurrence
  • There is no benefit of 7-day local treatment over a single oral dose of fluconzole. If oral treatment is contraindicated, it is more logical to repeat a single dose pessary after three days
  • Low-potency corticosteroids are also thought by some experts to improve symptomatic relief in conjunction with adequate antifungal therapy

Diabetes mellitus

  • Symptomatic vulvovaginal candidiasis is more prevalent in this group of patients. It is most problematic in those with poor glycaemic control
  • When C. albicans is isolated, single-dose fluconazole (150 mg) gives a similar response to patients without diabetes
  • Symptomatic women with C. glabrata isolated: refer to genito-urinary medicine (GUM)

HIV Infection

  • Vulvovaginal candidiasis occurs more frequently and with greater persistence in HIV-infected women. Treat by conventional methods including the use of suppressive antifungal regimens if necessary

Non-albicans species

  • Seek specialist advice for the treatment of non-albicans Candida species infection

full guidelines available from…
BASHH Secretariat: Royal Society of Medicine, 1 Wimpole Street, London, W1G 0AE

United Kingdom national guideline on the management of vulvovaginal candidiasis Clinical Effectiveness Group & British Association of Sexual Health and HIV 2007, reviewed April 2012
First included: June 2012.