The patient’s unmet needs (PUNs)
A 29-year-old woman attends in your emergency surgery requesting a prescription for thrush. You note that she has repeated courses of topical antifungals in the past for the same problem, and on one occasion had an HVS which demonstrated candida. She is not keen to be examined – ‘I know the symptoms and it’s exactly the same’ she says – but she does ask why she suffers so many episodes. ‘I know there’s a tablet treatment – would that be better?’ she asks. ‘And should my partner be treated?’
The doctor’s educational needs (DENs)
Is it reasonable to treat empirically for thrush when the problem is recurrent and the symptoms typical?
For recurrent episodes, where possible, it is better to confirm the diagnosis of thrush with microscopy of the vaginal discharge and a vaginal swab for culture. Whereas the classic symptoms of thrush are vulval itch, vaginal discharge, vulval soreness and superficial dyspareunia, none of these symptoms are pathognomonic for vulvovaginal candidiasis per se. There are many other conditions that can be responsible for similar symptoms, and therefore corroborative evidence of laboratory tests should be sought. Candida identified via a culture can also help specify the species of candida.
Clinical examination to rule out any other dermatological conditions contributing to some of these symptoms should be performed. For uncomplicated thrush, it is usual to use topical therapies such as clotrimazole pessaries (500mg) in combination with clotrimazole vaginal cream (10%), or oral preparations such a fluconazole 150mg stat. For recurrences as an initial regimen, topical therapy can be increased to 10 to 14 days, depending on clinical response. Sequential clotrimazole pessaries (500 mg) can also be initiated weekly for three weeks, but should be avoided in pregnancy. Treatment of recurrent vulvovaginal candidiasis with oral azole therapy is usually initiated in the genitourinary clinic setting, as these treatments are not licensed for use in this indication.
What are the main differential diagnoses?
Other vaginal infections, such as bacterial vaginosis, can also give rise to vulval soreness and vaginal discharge, and therefore identification of spores via microscopy would be recommended where symptoms are recurrent. Dermatological conditions such as lichen sclerosus predominantly present with symptoms of vulval itching, soreness and superficial dyspareunia. Other differentials include dermatitis and possible allergic reactions, which can contribute to similar symptoms.
Why do some patients suffer recurrences?
Recurrent vulvovaginal candidiasis is defined by at least four documented episodes of symptomatic vulvovaginal candidiasis annually, with at least partial resolution of these symptoms between episodes. Positive microscopy for vaginal spores or moderate to heavy growth of candida albicans should be documented on at least two occasions when symptomatic. Approximately 5% of women with a primary episode of vulvovaginal candidiasis will develop recurrent disease.
This is caused by a variety of host factors. It is usually due to Candida albicans. Conditions such as uncontrolled diabetes and immunosuppression, either by immunosuppressive medication or immunosuppressive conditions, can also contribute to recurrent episodes of thrush. Hyperoestrogenemia, including the use of HRT and the combined oral contraceptive pill, are also factors. Disturbance of vaginal flora, for example, through the use of broad spectrum antibiotics and over washing with shower gels, perfumed soaps and use of bubble baths, can also impact on a disturbance in the vaginal flora, giving rise to recurrent thrush.
Is oral treatment more effective than topical treatment? What can be done to prevent recurrences?
Topical and oral azole therapies do give a clinical and mycological cure in over 80% of uncomplicated acute vulvovaginal candidiasis, and it is a matter of choice of personal preference, availability and affordability as to which preparation is used. Topical azole therapies can cause some vulvovaginal irritation, and this should be considered if symptoms worsen or persist. In order to prevent recurrences, general advice for all vulval conditions consists of avoiding contact with soap, shampoo and bubble baths. Simple vulval emollients can be used as a soap substitute. Avoidance of tight fitting garments, which may irritate the area, is recommended. More specifically, contraception should be reviewed and the avoidance of high oestrogen-containing contraceptives would be advisable. Consider the exclusion of any other chronic illnesses, which could impact on the frequency of recurrent episodes.
Treatment for recurrent episodes of azole-sensitive candidiasis involves an induction regimen followed by maintenance therapy. Specific regimens include an induction with three doses of fluconazole 150mg every 72 hours, followed by a maintenance dose of fluconazole 150mg once a week for six months. With this regimen, 90% of women should remain disease free. Such regimens are unlicensed for the indication.
Is there any logic in treating her partner? And in intractable cases, should she be referred to a genitourinary clinic or a gynaecologist?
There is no evidence to support the treatment of asymptomatic male sexual partners in either episodic or recurrent vulvovaginal candidiasis. Intractable cases of vulvovaginal candidiasis should be referred to a genitourinary clinic where access to microscopy and vaginal culture of thrush is available – the latter is important to identify the species of Candida. In some cases of recurrent intractable thrush, there is a possibility of non-albicans species being identified. The majority are Candida glabrata, which is still susceptible to available azoles. Candida krusei is resistant to fluconazole. There are alternative treatments available for treatment of non-albicans Candida, but for the purpose of this article specific treatments for these have not been included here.
Predominant causative agent is Candida albicans, which will be present in 80% to 90% of cases. Non-albicans species such as C.glabrata, C.tropicalis, C.krusei, C.parapsilosis and Saccharomyces cerevisiae are also implicated, but are rare.
- Vulval itch
- Vaginal discharge
- Vulval soreness
- Superficial dyspareunia
- Non-offensive vaginal discharge and excretion
- Vulval dermatitis could result as a consequence of repeated vulvovaginal candidiasis
- Referral to a genitourinary clinic is advisable for intractable or recurrent episodes of vulvovaginal candidiasis.
- Avoid shower gels, soaps and bubble baths. Substite these with vulval emollients.
- Avoid of tight fitting clothing.
- Review contraception, avoid high-oestrogen contraceptives.
- Low oestrogen pills do not predispose to vulvovaginal candidiasis, but may possibly have a negative influence on relapsing episodes.
- Exclude of diabetes and other immunosuppressive causes.
- Either topical or oral regimens can be considered for the treatment of recurrent thrush. The principal of therapy involves an induction regimen to ensure clinical remission, followed immediately by a maintenance regimen.
Dr Deepa Grover is a consultant in genitourinary medicine at the Royal Free Hospital, London.
Clinical effectiveness group, British Association of Sexual Health and HIV. United Kingdom national guideline on the management of vulvovaginal candidiasis. London; BASHH: 2007
Sobel JD, Faro S, Force RW et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol, 1998;178(2):203-211
Nyirjesy P. Chronic vulvovaginal candidiasis. Am Fam Physician, 2001;63(4):697-702
Hurley R. Recurrent candida infection. Clinics in Obstetrics & Gynaecology, 1981; 8(1):209-214