Thrush is the common name used when Candida species cause vulvovaginal symptoms. Asymptomatic carriage should be referred to as candidosis. Vulvovaginal candidiasis is usually (80-90%) caused by Candida albicans. In a small minority of cases, non-albicans species such as Candida glabrata may be incriminated. The clinical features of the albicans and non-albicans species are however indistinguishable.

Presentation of Vulvovaginal Candidiasis

Vulvovaginal candidiasis may be associated with vulval itchiness or vulval soreness. Some women may have a vaginal discharge that characteristically is described as being curdy and with at worst a mild smell.

The vulval soreness may contribute to superficial dyspareunia.

Examination of a woman with vulvovaginal candidiasis may reveal varying degrees of vulval erythema and oedema. The discharge may be seen in the vagina or coating the vaginal walls. In extreme cases, fissuring of the vulva may be seen. None of these symptoms or signs is specific for the diagnosis of candidiasis.

Candidiasis is often diagnosed on the basis of clinical features alone and as many as half of these women may have other conditions, e.g. allergic reactions. During their reproductive years, 10-20% of women may harbour Candida species in the absence of symptoms. These women do not require treatment.

Complications of Vulvovaginal Candidiasis

There are no significant complications.

Diagnosis of Vulvovaginal Candidiasis

Clinical

In most cases of women presenting in general practice settings, a diagnosis of candidiasis is made on clinical grounds.

The pH of vaginal fluid tends to remain acidic (4.0-4.5) in cases of candidiasis. (If pH>4.5, suspect bacterial vaginosis/trichomoniasis).

Microscopic diagnosis

The diagnosis of candidiasis is confirmed by microscopy of a Gram-stained smear of discharge collected from anterior fornix or lateral vaginal wall. The presence of spores or pseudohyphae helps in confirming the diagnosis, although the sensitivity of microscopy is less than 65%.

Culture

Confirmation of the diagnosis by culture needs culture on Sabouraud’s media. This should be considered in all symptomatic cases for which microscopy is inconclusive or identification of the species would be helpful, e.g. multiple previous treatments or concerns regarding the species involved. Since Candida species can be commensal organisms and grow easily, a positive culture does not mean that a woman’s symptoms are due to the yeast.

Treatment of Vulvovaginal Candidiasis

Treat only if symptomatic or if asymptomatic infection is present and antibiotics are being given for another indication.

A variety of preparations are available for the treatment of thrush. One simple and effective method (80-95% cure) is to give azole vaginal pessaries, e.g. clotrimazole 500 mg vaginal pessary as a single dose. If there is significant vulvitis, this can be combined with 1% clotrimazole cream applied to the vulva two or three times daily for up to 5-7 days, to relieve the vulval itch.

Clotrimazole cream on its own is of limited use.

Clotrimazole cream and pessaries can damage condoms, so alternative contraception should be used.

Alternatives to topical treatment are oral azoles, e.g. fluconazole as a single 150-mg oral dose or itraconazole (200 mg) taken twice a day for 1 day. These are no more effective than topical treatments. Oral therapies should be avoided in pregnancy or if there is any risk of an early pregnancy or if the woman is breast feeding.

Recurrent candidiasis

This is defined as four or more episodes of symptomatic candidosis annually. Prevalence is less than 5% of healthy women in their reproductive years. Pathogenesis of this condition is poorly understood. It is important to confirm that candidosis is really the cause of the symptoms — it could be another cause of chronic itch (see Genital itch, page 33)

Sometimes recurrent candidiasis is due to drug-resistant strains of C. albicans or to innately resistant species such as C. glabrata or C. parapsilosis. In recurring cases it is therefore important to ask your lab to determine the species and its antifungal sensitivity (fluconazole is the one usually tested against).

Regimens used are not based on randomized controlled trials. The basis of these regimens is induction with an anti-fungal agent, followed by a maintenance regimen for 4-6 months. Induction may involve using 200-mg clotrimazole pessaries for 3 days along with simultaneous topical use of clotrimazole cream, which is continued for 2 weeks or so. This is followed with the use of weekly clotrimazole 500-mg pessaries for 4-6 months or alternatively itraconazole 400 mg monthly for 4-6 months. Women on long-term oral antifungals should have their liver enzymes checked after a month.

Failure of routine antifungals to relieve symptoms can prove frustrating for both the patient and her practitioner. Referral to a specialist may sometimes be useful in these situations.

Candidiasis in pregnancy

Symptomatic candidiasis is more common in pregnant women than in non-pregnant women. Treatment with topical azoles is recommended and longer courses may be necessary. Oral therapy is contraindicated.

Sexual partner(s)

There is no evidence to support treatment of asymptomatic male partners.

Other management

General advice such as avoiding local irritants (perfumed soaps, deodorants, shower gel etc.) and avoiding tight-fitting synthetic clothing may prove helpful.

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