29th July 2023

Vulvovaginal candidiasis

Also known as genital thrush, vulvovaginal candidiasis presents as localised inflammation of the vagina or vulva. Around 90% of cases are due to Candida albicans. It is a common condition that can affect any person with female genitalia, regardless of age. It is generally due to the overgrowth of commensal candida and is strongly associated with antibiotic therapy leading to disruption to the balance of natural vaginal flora.

Other risk factors for vulvovaginal candidiasis include oestrogen excess (e.g. pregnancy. HRT), use of local irritants such as soaps and douches, and immunocompromise (see below).

Acute infection refers to an isolated infection. Recurrent candida is defined as 4 or more symptomatic episodes in 1 year, and can indicate an underlying disease causing immunosuppression; hence warrants investigation for diabetes mellitus and HIV. Long-term steroid use is also associated with recurrent candida due to immunosuppression.

Diagnosis can generally be made clinically, and if the diagnosis is apparent from the history, an external examination may not be indicated. However, this should be done if the diagnosis is uncertain, and if laboratory confirmation is required, then high-vaginal swabs and cultures are the main diagnostic test. STI screening may also be indicated.

For acute infection, management includes symptomatic measures such as emollients, avoiding irritants like soap, and wearing loose-fitting clothing. The drug treatment of choice is single dose oral fluconazole or single dose clotrimazole, pessary if fluconazole is contraindicated. Vulval disease can be co-treated with topical or intravaginal clotrimazole, which is available over the counter.

For recurrent infection, an induction dose of 3 doses of oral fluconazole is given, followed by a 6 month course of once-weekly doses, with appropriate follow up arranged.

Oral fluconazole is not recommended in pregnancy – topical or intravaginal formulations are used instead.