This guideline offers recommendations on the diagnostic tests, treatment regimens, and health promotion principles for the effective management of acute and recurrent vulvovaginal candidiasis (VVC).
This Guidelines summary only covers key recommendations for primary care. For the complete set of recommendations, see the full guideline.
Vulvovaginal Candidiasis Diagnostic and Management Pathway
Algorithm 1: Vulvovaginal Candidiasis Diagnostic and Management Pathway
Clinical Features
- Vulvovaginal candidiasis (VVC) typically presents with:
- vulval itch and
- a non-offensive vaginal discharge
- Other symptoms can include:
- soreness or burning
- superficial dyspareunia
- cyclical symptoms
- Clinical signs may include:
- erythema
- fissuring
- swelling/oedema
- vaginal discharge typically non-offensive and curdy but may be thin or absent
- there may also be satellite lesions and excoriation marks
- None of these features are pathognomonic for VVC and there can be a significant discrepancy between symptoms and signs, particularly in chronic disease. Although Candida albicans is the most pathogenic of the Candida species, clinical symptoms or signs cannot be used to guide which Candida sp. is the cause for the infection. Health-related quality of life—both physical and psychological—is significantly affected in recurrent VVC
- In women with recurrent VVC, enquiry about other recurrent infections, particularly those suggestive of fungal infection (for example, oropharyngeal, skin, nails, dandruff) is relevant. Rarely, the history may indicate an immune defect and the need for referral to immunology for assessment.
Diagnosis
- VVC is a clinical diagnosis based on typical features supported by laboratory confirmation of Candida sp. from a vaginal sample
- In women presenting with clinical features of acute VVC to a service providing level three STI care, supporting the diagnosis with routine microscopy is good clinical practice
- Recurrent VVC is defined as four or more symptomatic episodes over a 12-month period. At least two of these episodes should be confirmed by microscopy or culture; one of these should be a positive culture with moderate or heavy growth of Candida sp.
Clinical Examination and Syndromic Management
- Clinical examination of the external genitalia is recommended in women presenting with symptoms suggestive of acute VVC in order to exclude alternative or co-existing vulvovaginal pathologies
- Women presenting with features suggesting recurrent VVC should always have a clinical examination
- Where clinical examination is not possible or required, self-collected vaginal swab for microscopy and/or culture is a reasonable alternative to clinician-taken samples
- Empirical treatment for acute VVC based on the reported symptoms may be given in non-specialist settings; if the symptoms do not resolve, or if they recur, examination and microbiological testing should be performed (see the full guideline).
Management
General Advice for All Women with VVC Symptoms
- Patients should be provided with information about the importance of good skin care:
- avoiding the use of local irritants such as perfumed soaps or wipes
- the use of an emollient for personal hygiene as a soap substitute, as a moisturiser and a barrier cream (patient needs to be informed that this does not constitute ‘internal use’)
- Sex does not need to be avoided from an infection perspective as VVC is not a sexually transmitted infection. Women may wish to avoid sex until symptoms have improved, particularly if there is fissuring of the skin.
Treatments
Acute VVC
- Recommended regimen:
- fluconazole[A] capsule 150 mg as a single dose, orally
- Recommended topical regimen (if oral therapy contraindicated):
- clotrimazole pessary 500 mg as a single dose, intravaginally[B]
- Alternative regimens:
- clotrimazole vaginal cream (10%) 5 g as a single dose, intravaginally[B]
- clotrimazole pessary 200 mg intravaginally at night for 3 consecutive nights[B]
- econazole pessary 150 mg intravaginally as a single dose or 150 mg intravaginally at night for 3 consecutive nights[B]
- fenticonazole capsule intravaginally as a single dose 600 mg or 200 mg intravaginally at night for 3 consecutive nights[B]
- itraconazole 200 mg orally twice daily for 1 day PO[A]
- miconazole capsule 1200 mg intravaginally as a single dose, or 400 mg intravaginally at night for 3 consecutive nights[B]
- miconazole vaginal cream (2%) 5 g intravaginally at night for 7 consecutive nights.[B]
Severe Vulvovaginal Candidiasis
- Recommended regimen:
- fluconazole 150 mg orally on day 1 and 4
- Alternative regimens:
- clotrimazole 500 mg pessary intravaginally on day 1 and 4
- miconazole vaginal capsule 1200 mg on day 1 and 4
- Low-potency corticosteroid creams are also thought by some experts to accelerate symptomatic relief in conjunction with adequate antifungal therapy.
Recurrent VVC
- Recommended regimen:
- induction: fluconazole 150 mg orally every 72 hours x 3 doses[A]
- maintenance: fluconazole 150 mg orally once a week for 6 months[A]
- Alternative regimens:
- induction: topical imidazole therapy can be increased to 7–14 days according to symptomatic response
- maintenance for 6 months:
- clotrimazole pessary 500 mg intravaginally once a week
- itraconazole 50–100 mg orally daily.[A]
Pregnancy and Breastfeeding
- Recommended regimens (acute VVC in pregnancy):
- clotrimazole pessary 500 mg intravaginally at night for up to 7 consecutive nights[C]
- Alternative regimens (acute VVC in pregnancy):
- clotrimazole vaginal cream (10%) 5 g intravaginally at night for up to 7 consecutive nights[C]
- clotrimazole pessary 200 mg intravaginally at night for up to 7 consecutive nights
- econazole pessary 150 mg intravaginally at night for up to 7 consecutive nights
- miconazole capsule 1200 mg[C] or 400 mg intravaginally at night for up to 7 consecutive nights
- miconazole vaginal cream (2%) 5 g intravaginally at night for 7 consecutive nights
- Recommended regimen (recurrent VVC in pregnancy):
- induction: topical imidazole therapy can be increased to 10–14 days according to symptomatic response
- maintenance: clotrimazole pessary 500 mg intravaginally weekly
- Recommended regimens (acute and recurrent VVC in breastfeeding):
- treatment regimens using topical imidazoles should be as per the recommendations listed above for non-pregnant women with acute and recurrent VVC.
Alternative or Supplementary Treatments
- Some evidence of benefit:
- anti-allergy:
- cetirizine 10 mg orally daily for 6 months may cause remission in women who fail to get complete resolution of symptoms with suppressive fluconazole
- zafirlukast 20 mg orally twice daily for 6 months may be considered as maintenance prophylaxis for recurrent VVC, particularly in women with a history of atopy (zafirlukast production was discontinued in the UK in 2018, commercial reasons are cited for this decision and it is stressed that there were no safety concerns; the closest available alternative is montelukast but this has not been studied in the setting of VVC)
- anti-allergy:
- Insufficient or no evidence of benefit:
- probiotics: there continues to be insufficient evidence to support the use of oral or vaginal probiotics (mainly Lactobacilli) for the treatment or prevention of VVC:
- an increasing number of studies suggest that their adjunctive use may improve clinical outcomes or reduce the likelihood of recurrence; however, the quality of evidence is variable and inconsistent in terms of the probiotic or regimen used
- the mode of action might be via modulation of inflammatory processes rather than competition with Candida
- tea tree and other essential oils: are antifungal in vitro but they may cause hypersensitivity reactions. There is insufficient evidence to recommend use in recurrent VVC
- breathable underwear with antimicrobial protection: there is insufficient evidence to recommend their use in recurrent VVC. Small studies have shown a reduction in itching, burning, erythema and recurrences compared with cotton briefs in women with recurrent VVC on a standard fluconazole suppressive regimen
- yoghurt and honey mixes: there is insufficient evidence to support the use of vaginal applications of yoghurt and honey mixes, although there have been some reports of benefit with symptom improvement
- diet: there is no evidence to support any dietary modifications, including reducing carbohydrate or yeast intake
- oral garlic: there is no evidence of benefit from oral garlic on Candida colonisation. Observational studies have shown that garlic taken orally may cause heartburn, nausea, diarrhoea, flatulence, bloating, and an offensive body odour.
- probiotics: there continues to be insufficient evidence to support the use of oral or vaginal probiotics (mainly Lactobacilli) for the treatment or prevention of VVC:
For more information on treatment of VVC for women with diabetes mellitus, HIV infection, hormones and contraception information, reactions to treatment, and follow-up, see the full guideline.
Footnotes
[A] Oral therapies must be avoided in pregnancy, risk of pregnancy and breastfeeding; topical imidazoles are a safe and effective alternative in these situations (see ‘Pregnancy and Breastfeeding’ section)
[B] Intravaginal and topical treatments can also damage latex condoms and diaphragms with case reports of unplanned pregnancies; women must be appropriately counselled about this risk
[C] Duration of therapy: longer courses are recommended in pregnancy
References
References