Candida, genital thrush

Comments from Expert Advisory Group

Candida can lead to genital symptoms in men and women. Asymptomatic colonisation is common and does not always need to be treated. The majority of cases are caused by Candida albicans.
In women it can lead to vulvitis, vaginitis and / or vulvovaginitis. Symptoms may include thick white vaginal discharge, vulval discomfort or itch. Other symptoms include non-offensive odour and dyspareunia / dysuria and signs include vulval erythema / fissuring and satellite lesions.
In men it can present with a balanitis with an associated itch.
The diagnosis can be made clinically on the basis of the description and appearance of the vulva, vaginal discharge or glans penis in men. A high vaginal swab (HVS) is not required to start empiric treatment on first presentation.  A HVS can be useful in women experiencing recurrent symptoms or failing to respond to treatment in order to confirm the presence of candida, the type of candida species and sensitivities where resistance to azoles is suspected. Azole resistance is not common.
In women, consider sexually transmitted causes of vaginal discharge on the basis of sexual history and consider testing for chlamydia, gonorrhoea and trichomoniasis.
All women should be examined and a differential including genital dermatoses be considered.
The definition of recurrent vulvovaginal candidiasis is accepted as four or more episodes per year, two of which are confirmed on microscopy or culture when symptomatic. Careful consideration should be given to alternative diagnoses such as lichen sclerosis, eczema or other dermatological conditions. Referral to GUM or dermatology may be warranted.  The vulval skin care leaflet from British Association of Dermatology contains general advice for patients.
Identify and optimise the management of underlying conditions or risk factors for genital thrush such as undiagnosed or poorly controlled diabetes.
In general, treatment of asymptomatic sexual partners is not recommended.

Treatment Options

Emollient creams may be used as a soap substitute, moisturiser and / or barrier cream (external use only). Advise to avoid vaginal douching and irritants such as soaps and shower gels.
1% hydrocortisone may ease symptoms of vulvitis and balanitis.
Intravaginal and oral treatments have similar efficacy in the management of vulvovaginal candidiasis.

There are many treatment options available, the table below is not exhaustive.

GENITAL THRUSH (CANDIDA) ANTIMICROBIAL TREATMENT TABLE

Vulvovaginal candidiasis

Short course topical and / or intravaginal formulations effectively treat uncomplicated vulvovaginal candidiasis.
Choice of treatment should be made on the basis of location of symptoms and patient choice. A number of preparations are available over-the-counter (OTC).
If there are vulval symptoms, consider clotrimazole cream for external relief of symptoms in addition to intravaginal or systemic antifungal if required.

Drug

Dose

Duration

Notes

Clotrimazole 1% or 2% cream

Useful for vulval symptoms.

available OTC

Apply to the affected area every 8 to 12 hours.

Until symptoms resolved, up to 7 days.

Use of 1% hydrocortisone in combination with azole cream may be required.

Clotrimazole may damage latex condoms and diaphragms, extra precautions advised.

Clotrimazole (Canesten^®) pessary

available OTC

500mg intravaginal pessary

single dose

Insert pessary using applicator high into the vagina at night.

Latex condoms and diaphragms can be damaged by pessaries; extra precautions are advised.

Econazole (Gyno-Pevaryl^®) pessary

available OTC

150mg intravaginal pessary

single dose

Fluconazole oral

prescription only

150mg

single dose

Avoid fluconazole (and all oral azoles) in pregnancy.

Vulvovaginal candidiasis in pregnancy

Clotrimazole (Canesten^®) pessary

500mg intravaginal pessary at night

Up to 7 days

Use of an applicator into the vagina not recommended during pregnancy.

Recurrent vulvovaginal candidiasis (note definition in expert advisory comments above)

Fluconazole oral

prescription only

150mg

On day 1, 4 and 7, then weekly for 6 months

Check for drug interactions

Avoid fluconazole (and all oral azoles) in pregnancy

Recurrent vulvovaginal candidiasis in pregnancy

Clotrimazole (Canesten^®) pessary

500mg intravaginal pessary at night for up to max. 10-14 days according to symptomatic response

followed by maintenance: 500mg intravaginal pessary once weekly

Duration detailed with dose

Use of an applicator into the vagina not recommended during pregnancy.

Candida balanitis

Clotrimazole 1% cream

available OTC

Apply to the affected area every 12 hours.

Up to 14 days according to symptomatic response.

Clotrimazole may damage latex condoms, extra precautions advised.

Oral treatment rarely indicated.

Patient Information

Patients should be advised to avoid tight fitting clothing and the use of soaps and shower gels.
Further information is available in the genital thrush patient information leaflet
Patient information on STIs and genital conditions is available at the HSE Sexual Health and Crisis Pregnancy website

Safe Prescribing

Visit the safe prescribing page

Doses are oral and for adults unless otherwise stated
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions tables
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed April 2024