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This summary has been developed for use by community pharmacists under our Guidelines for Pharmacy title and therefore only covers the information relevant to this setting. Please refer to the full guideline for the complete set of recommendations.

What is it?

  • Vulvovaginal candidiasis (genital thrush) is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection
  • Vulvovaginal candidiasis can be classified as:
    • uncomplicated, which is:
      • sporadic or infrequent, and
      • mild to moderate, and
      • likely to be due to C. albicans, and
      • is not associated with risk factors, such as pregnancy or poorly controlled diabetes
    • complicated, which includes:
      • recurrent infection—defined as four or more documented episodes in 1 year, with at least partial resolution of symptoms between episodes
      • severe infection
      • infection with yeasts other than C. albicans
      • infection during pregnancy
      • infection in women with uncontrolled diabetes, women with immunocompromising conditions (such as HIV infection), and women taking immunosuppressive drugs (such as systemic corticosteroids)

What are the complications?

  • Treatment failure (failure of symptoms to resolve within 7–14 days of treatment)
  • Depression and psychosexual problems may affect women who have recurrent vulvovaginal candidiasis
  • Candidal balanitis may occur rarely in male partners of women with vulvovaginal candidiasis

What are the risk factors

  • The risk factors for uncomplicated vulvovaginal candidiasis include:
    • oestrogen exposure — the condition is more common during the reproductive years and during pregnancy
    • immunocompromised state
    • poorly controlled diabetes mellitus
    • treatment with broad-spectrum antibiotics —vulvovaginal candidiasis occurs in about 30% of women taking systemic or intravaginal antibiotics
    • local irritants —e.g. soaps, shower gels, ‘feminine hygiene’ products, and tight-fitting, synthetic clothing 
    • sexual behaviours —vulvovaginal candidiasis can be triggered by sex, especially if there is vaginal dryness and tightness during intercourse
    • contraception
      • spermicidal jellies and creams 
      • oral contraceptive pills, especially combined oral contraceptives (COCs)
    • hormone replacement therapy (HRT)

How should I assess a woman with suspected vulvovaginal candidiasis?

  • Take a history
    • ask about the symptoms experienced, including the duration, severity, and exacerbating factors. Symptoms of vulvovaginal candidiasis include:
      • vulval itching (often the defining symptom)
      • vulval soreness and irritation
      • vaginal discharge (usually white, ‘cheese-like’, and non-malodorous)
      • superficial dyspareunia
      • dysuria (pain or discomfort during urination)
    • enquire whether the infection is:
      • an isolated episode, or
      • a recurrence (defined as four or more documented episodes in 1 year, with at least partial resolution of symptoms between episodes), or
      • treatment failure (failure of symptoms to resolve within 7–14 days of treatment)
    • ask about any treatments that have been tried already, including over-the-counter treatments
    • enquire about the presence of risk factors, such as recent use of a broad-spectrum antibiotic
    • consider whether the person is at risk for a sexually transmitted infection.
      • sexually active women are at higher risk of an STI if they are aged younger than 25 years, or have changed their sexual partner or had more than one sexual partner in the last 12 months. Other risk factors include a lack of consistent condom use and a previous diagnosis of chlamydia infection in the last 12 months
    • ask about the presence of other symptoms, to exclude alternative diagnoses. For example:
      • foul smelling or purulent discharge could indicate a bacterial infection
      • urinary frequency and urgency could indicate a urinary tract infection (UTI)
      • abnormal vaginal bleeding could indicate an STI or cancer
  • Examination is not routinely recommended if the history indicates uncomplicated vulvovaginal candidiasis.
    • consider the need for GP referral for an examination to assess the severity of the infection and/or to exclude alternative diagnoses, for example in women with severe symptoms, women at high risk of an STI, or if an alternative diagnosis is suspected

How should I manage uncomplicated vulvovaginal candidiasis?

  • Prescribe antifungal treatment.
    • the choice of treatment and formulation will depend on factors such as contraindications and cautions, the licenced age and indication for the product, and the person’s preference
      • for most women, prescribe an initial course of an intravaginal antifungal cream or pessary (clotrimazole, econazole, miconazole, or fenticonazole) or an oral antifungal (fluconazole or itraconazole)
      • for women aged 60 years and older, oral antifungals may be more acceptable than intravaginal antifungals because of the ease of administration
      • for girls aged 12–15 years, consider prescribing topical clotrimazole 1% or 2% applied 2–3 times a day, or seek specialist advice. Do not prescribe an intravaginal or oral antifungal
      • for breastfeeding women, prescribe an initial course of intravaginal clotrimazole or miconazole, or oral fluconazole (if an intravaginal antifungal is unacceptable to the woman)
    • if there are vulval symptoms, consider prescribing a topical imidazole in addition to an oral or intravaginal antifungal. Options include:
      • clotrimazole 1% or 2% cream applied 2–3 times a day
      • ketoconazole 2% cream applied 1–2 times a day (for adults aged 18 years and older)
  • Advise the woman:
    • to return if symptoms have not resolved within 7–14 days
    • on measures to aid symptom relief and prevent recurrence
  • Prescribers should be aware the use of topical anti-fungals may affect the effectiveness of latex contraceptives

What advice on self-management should I give?

  • Advise the woman to:
    • avoid the following potential predisposing factors:
      • washing and cleaning the vulval area with soap or shower gels (including those containing perfume and antiseptics [such as tea tree oil]), wipes, and ‘feminine hygiene’ products
      • cleaning the vulval area more than once a day
      • washing underwear in biological washing powder and using fabric conditioners
      • vaginal douching
      • wearing tight-fitting and/or non-absorbent clothing.
    • wash the vulval area with a soap substitute—this should be used externally and not more than once a day
    • use a simple emollient to moisturise the vulval area
    • consider using probiotics (such as live yoghurts) orally or topically to relieve symptoms

How should I manage treatment failure following treatment for uncomplicated vulvovaginal candidiasis?

  • If symptoms have not resolved within 7–14 days of initial treatment:
    • confirm that the initial treatment was used as recommended
    • be aware that topical treatments can cause vulvovaginal irritation, which may be mistaken for treatment failure
    • reassess for risk factors and remove or control as far as possible
    • consider alternative diagnoses (refer to GP for tests)
    • treat the infection
      • if there has been a lack of compliance with the initial treatment formulation, prescribe the alternative formulation (for example, prescribe oral treatment if there has been poor compliance with intravaginal treatment)
      • if compliance is good and symptoms are improving, consider treating with an extended course of an oral antifungal (fluconazole or itraconazole) or an intravaginal antifungal (clotrimazole, econazole, or miconazole)
      • for breastfeeding women, consider treating with an extended course of intravaginal clotrimazole or miconazole, or seek specialist advice
    • reinforce self-management advice
    • refer or seek specialist advice (using clinical judgement) if:
      • the person is aged 12–15 years
      • there is doubt about the diagnosis
      • symptoms are not improving and treatment failure is unexplained
      • a non-albicans Candida species is identified
      • treatment fails again

© NICE 2017. NICE CKS on candida—female genital. Available from: cks.nice.org.uk/candida-female-genital. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Last updated: May 2017.