Vaginal thrush

• Candida species can be normal flora and therefore not need treatment if asymptomatic.
• Can be sexually transmitted but is not considered a sexually transmitted infection (STI).
• Can arise spontaneously or secondary to disturbance of vaginal flora
  • antibiotic therapy
  • increased oestrogen levels
    • pregnancy
    • postmenopausal oestrogen therapy.

Cause

• Majority Candida albicans, rarely other Candida species.

Symptoms

• Penile
  • Red rash on genitals, especially under foreskin, may or may not be itchy
  • Swelling of foreskin if severe
  • Fissures
  • Superficial erosions
• Vulvar/vaginal
  • Thick, white, clumping vaginal discharge although discharge can appear normal or be absent
  • Genital/vulvar itch, burning, soreness
  • Superficial dyspareunia
  • External dysuria
  • Excoriation, erythema, fissures, swelling

Special considerations

• Recurrent candidiasis is defined as 4 or more episodes in a 12-month period and may occur in nearly 10% of women. It should be confirmed by culture on at least one occasion.
• Other causes for symptoms must be excluded by genital examination e.g. dermatitis, lichen sclerosis, herpes simplex viruses (HSVs).
• Consider diabetes mellitus, human immunodeficiency virus (HIV) infection or other causes of immunosuppression if poorly controlled disease.

Diagnosis

• High vaginal swab or self-collected vaginal swab- Microscopy and culture (MCS)

Treatment advice

• Intravaginal and oral azoles have similar efficacy – topical therapy provides quicker symptom relief but women generally prefer oral therapy.
• Vulvar treatment alone is inadequate due to a vaginal reservoir – both sites should be treated.
• The addition of hydrocortisone 1% cream may provide symptomatic relief.
• No evidence that specific diets or use of probiotics influence recurrence.
• Reconsider diagnosis if no response to therapy.
• Oral azoles cannot be used in pregnancy.
• No hepatic monitoring is required for fluconazole use at the above doses.

• Other immediate management
  • Avoid local irritants
    • e.g. soap, bath oil, body wash, bubble bath, spermicide, vaginal lubricant and vaginal hygiene products.
  • Latex barrier contraception e.g. condoms can be damaged by antifungal vaginal creams or oil-based products.
  • Post-coital penile hypersensitivity to vaginal Candida colonisation is possible and responds to partner treatment Hydrocortisone 1% cream may provide symptomatic relief. 
  • Partners do not usually require treatment.

Principal treatment option
Situation		Recommended		Alternative
	Uncomplicated		Vaginal azole creams (e.g. clotrimazole 10% vaginal cream, 1 applicator intravaginally at night, as stat. dose or 3-7 day course) or 500 mg clotrimazole vaginal pessary stat.For balanitis, treat with Clotrimazole 1% twice daily until symptoms settle then for a further week.		Fluconazole 150 mg PO, stat.
	Recurrent Candida albicans		Treat each episode with longer course of azole cream (rather than stat. dose) and/or induction with fluconazole 150 mg PO, for 3 doses, 3 days apart, followed by maintenance with fluconazole 150 mg PO, weekly for 6 months		Clotrimazole 10% vaginal cream                    (I applicator) nightly for 10-14 days then 500mg vaginal pessary weekly after induction.
	Candida glabrata		Boric acid 600 mg vaginal pessaries (from a compounding pharmacy), one nocte for 14 days (boric acid can be fatal if ingested, avoid in pregnancy)		100 000 IU nystatin inserted per vaginally for 14 days

Special considerations

• More severe disease and symptoms may need longer courses of oral or topical treatment.
• Consider seeking specialist advice before treating complicated presentations or recurrent disease that is not responding to therapy.

Situation	Recommended
Pregnant people	May need longer course of topical treatment (e.g. 7 days minimum). Fluconazole/boric acid contraindicated.
Allergy to principal treatment choice	Try alternative treatment