4.2 Candidiasis

Question 1

What is candidiasis?

Answer 1

Vaginal candidiasis is commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans.

Candida may colonise the vagina without causing symptoms.
It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.

Question 2

Risk factors for candidiasis?

Answer 2

• Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
• Poorly controlled diabetes
• Immunosuppression (e.g. using corticosteroids)
• Broad-spectrum antibiotics

Question 3

Presentation of vaginal candidiasis?

Answer 3

The symptoms of vaginal candidiasis are:

• Thick, white discharge that does not typically smell
• Vulval and vaginal itching, irritation or discomfort

More severe infection can lead to:

• Erythema
• Fissures
• Oedema
• Pain during sex (dyspareunia)
• Dysuria
• Excoriation

Question 4

Investigations for candidiasis?

Answer 4

Often treatment for candidiasis is started empirically, based on the presentation.

Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).

A charcoal swab with microscopy can confirm the diagnosis.

Question 5

Management of vaginal candidiasis?

Answer 5

Treatment of candidiasis is with antifungal medications. These can be delivered in several ways:

• Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
• Antifungal pessary (i.e. clotrimazole)
• Oral antifungal tablets (i.e. fluconazole)

The NICE Clinical Knowledge Summaries (2017) recommend for initial uncomplicated cases the options of:

• A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
• A single dose of clotrimazole pessary (500mg) at night
• Three doses of clotrimazole pessaries (200mg) over three nights
• A single dose of fluconazole (150mg)

Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

They also recommend recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications. This is an off-label use.

Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.