Dr Andy Williams highlights key recommendations from the British Association for Sexual Health and HIV guideline on the management of vulvovaginal candidiasis

  • Women who self-diagnose VVC should have a clinical examination as many may also have other conditions
  • In women who are not pregnant, treatment of VVC should be based on the most cost-effective and acceptable topical or oral preparation
  • Healthcare professionals should recommend the use of vulval moisturisers as soap substitutes and skin conditioners
  • The effect of topical therapies on latex condoms and diaphragms should be considered
  • Fluconazole should be avoided in women who are pregnant, at risk of becoming pregnant, and women who are breast feeding
  • All women with severe symptoms should receive fluconazole 150 mg repeated after 3 days (unless contraindicated)
  • All women with proven recurrent VVC should be offered suppressive or alternative long-term therapy
  • Asymptomatic male partners should not be treated
  • There is no evidence to support any dietary interventions in the management of VVC
  • Complicated cases should be referred to the local GUM or sexual health service for consultant review.

Genital candidiasis, candidosis, or thrush is defined as pathogenic activity by commensal yeasts in the genital tract. It is a frequent complaint of women presenting to both general practice and sexual health services. The 2007 British Association for Sexual Health and HIV (BASHH) guideline on the management of vulvovaginal candidiasis1 (VVC) aims to educate practitioners on the management of this condition. The guideline covers the principles of diagnosis and treatment for the effective management of uncomplicated and complicated VVC in women aged 16 years or over. It is aimed at healthcare professionals working in departments that offer management of a full range of sexually transmitted infection (STI), however the guideline principles should be adopted across all services offering STI management with the development of referral pathways to the hospital setting if required.1

Diagnosis and management of vulvovaginal candidiasis

Vulvovaginal candidiasis is caused by Candida albicans in 80%–92% of cases.2,3However, the involvement of species other than C. albicans, such as C. glabrata, C. krusei, C. parapsilosis, C. tropicalis, and Saccharomyces cerevisiae should be considered (see below).1

Approximately 10%–20% of women during their reproductive years may be colonised with Candida species, 4,5 but have no clinical signs or symptoms. These women do not require treatment. The clinical features of VVC are non-specific and may include the following:1

  • symptoms such as:
    • vulval itch
    • vulval soreness
    • vaginal discharge
    • superficial dyspareunia
    • external dysuria
  • signs such as:
    • erythema
    • fissuring
    • odourless, curdy discharge (may be thin)
    • oedema
    • satellite lesions
    • excoriation.

None of the above symptoms or signs are pathognomonic for VVC and corroborative evidence from laboratory tests is therefore needed (alternative diagnoses include dermatitis, allergic reactions, and lichen sclerosus).1 Diagnosis of symptomatic women in the context of comprehensive sexual health services is made by routine microscopy and culture. A vaginal swab should be taken for:1

  • Gram or wet-film microscopy
  • directly plating on to solid fungal media; speciation to albicans/non-albicans is strongly preferred in uncomplicated VVC and is essential in complicated disease.

The BASHH guideline does not suggest the use of any other diagnostic tests and makes no reference to the use of high vaginal swabs. If there is uncertainty regarding the diagnosis, a referral to genitourinary medicine (GUM) services should be made for microscopy and consideration of Candida speciation and resistance.


Women should be advised to:1

  • use vulval moisturisers as a soap substitute and regular skin conditioner
  • avoid tight-fitting synthetic clothing
  • avoid local irritants (e.g. perfumed products).

As all topical and oral azole therapies provide a clinical and mycological cure rate of over 80% in uncomplicated acute cases of VVC, choice of treatment is a matter of availability, affordability, and patient preference.6,7

Treatment options are summarised in Table 1. Topical azole therapies can cause vulvovaginal irritation and this should be considered if symptoms worsen or persist. Follow up and test of cure in women with VVC are not necessary if symptoms resolve.

There is no evidence to support the treatment of asymptomatic male partners in either episodic or recurrent VVC.8,9

Table 1: Therapies for vulvovaginal candidiasis1
Drug Dosage regimen Formulation
Topical therapies
Clotrimazole* 500 mg stat Pessary
Clotrimazole* 200 mg x 3 nights Pessary
Clotrimazole* 100 mg x 6 nights Pessary
Clotrimazole* 5 g stat Vaginal cream (10%)
Econazole 150 mg stat Pessary
Econazole 150 mg x 3 nights Pessary
Fenticonazole 600 mg stat Pessary
Fenticonazole 200 mg x 3 nights Pessary
Isoconazole* 300 mg x 2 stat Vaginal tablet
Miconazole 1.2 g stat Ovule
Miconazole 100 mg x 14 nights Pessary
Nystatin 4 g x 14 nights Vaginal cream (100,000 units)
Nystatin 1–2 x 14 nights Pessary (100,000 units)
Oral therapies
Drug Dosage regimen  
Fluconazole 150 mg stat Capsule
Fluconazole 200 mg bd x 1 day Capsule
*Effect on latex condoms and diaphragms not known
†Product damages latex condoms and diaphragms
‡Avoid in pregnant women, if there is a risk of pregnancy, and in women who are breastfeeding
Reproduced with kind permission from the British Association of Sexual Health and HIV

Complicated vulvovaginal candidiasis


Asymptomatic colonisation with Candida species is more common in pregnancy and symptomatic candidiasis is more prevalent throughout pregnancy. Colonisation with Candida is not associated with low birth weight or premature delivery.10

Topical imidazoles should be used to treat symptomatic VVC in pregnant women.11 There is no evidence that any one topical imidazole is more effective than another. Longer treatment courses are recommended: a 4-day course will cure just over 50% of cases, whereas a 7-day course will cure over 90%.11 Oral therapy is contraindicated.1

Recurrent vulvovaginal candidiasis

Approximately 5% of women at a reproductive age who have a primary episode of VVC will develop recurrent disease.12,13 The BASHH guideline defines recurrent VVC as at least four documented episodes of symptomatic disease annually, with at least partial resolution of symptoms between episodes.1 Positive microscopy or a moderate/heavy growth of C. albicans should be documented on at least two occasions when the woman is symptomatic. Recurrent disease is caused by host factors, such as:1


  • diabetes mellitus
  • immunosuppression
  • hyperoestrogenaemia (including hormone replacement therapy and the combined oral contraceptive pill)
  • disturbance of vaginal flora (e.g. via use of broad-spectrum antibiotics)
  • association with allergies (in particular, allergic rhinitis)
  • pro-inflammatory genetic markers.

Women with recurrent VVC should be given the same general advice as those with uncomplicated disease (see under Management).

Vulval emollients may confer symptomatic relief as both secondary and primary vulval dermatitis is often present in VVC. Healthcare professionals should review the woman’s contraception—high-oestrogen contraceptives should be avoided.1

The basis of therapy for recurrent VVC involves an induction regimen to ensure clinical remission, followed immediately by a maintenance regimen (see Table 2).1 Approximately 90% of women will remain disease-free at 6 months and 40% at 1 year.14 Alternative treatment regimens for recurrent disease are shown in Table 3.

Alternative treatments

A number of alternative treatments have been suggested for the treatment of VVC:1

  • The role of allergy should be considered—zafirlukast 20 mg bd for 6 months may induce remission in women with a history of atopy
  • Oral or vaginal lactobacillus—there is no evidence to support the use of this therapy for the prevention of VVC
  • Diet—there is insufficient evidence to make any recommendations on dietary interventions, including carbohydrate or yeast intake
  • Tea tree oil (and other essential oils) is antifungal in vitro but may cause hypersensitivity reactions—there is insufficient evidence to recommend its use in recurrent VVC.

Vulvovaginal candidiasis and co-morbid conditions

Symptomatic VVC is more prevalent in people with diabetes and most problematic in those with poor control of blood glucose. It is therefore important that glycaemic control is optimised.1 There is an increased prevalence of non-albicans species, and in particular C. glabrata, in people with diabetes. If C. albicans is isolated in people with diabetes, single-dose fluconazole (150 mg) gives a similar response rate to that seen in non-diabetics.15

Vulvovaginal candidiasis occurs more frequently and with greater persistence in women with human immunodeficiency virus (HIV).16 Women should be treated by conventional methods, including the use of suppressive antifungal regimens if necessary.1 Severe VVC in any circumstances may require repeat treatment after 3 days to improve the symptomatic response.

Table 2: Recommended treatment regimen for recurrent vulvovaginal candidiasis 1
Treatment stage Drug Dosage regimen Formulation
Induction Fluconazole* 150 mg every 72 hours x 3 doses Capsule
Maintenance Fluconazole* 150 mg once a week for 6 months Capsule
*Avoid in pregnant women, if there is a risk of pregnancy and in women who are breastfeeding
Reproduced with kind permission from the British Association of Sexual Health and HIV
Table 3: Alternative regimens for recurrent vulvovaginal candidiasis1
Induction with topical imidazole therapy for 10–14 days according to symptomatic response followed by any of the maintenance regimens below for a period of 6 months
Maintenance regimen
Drug Dosage regimen Formulation
Clotrimazole 500 mg once a week Pessary
Fluconazole* 50 mg daily Capsule
Itraconazole* 50–100 mg daily Capsule
Ketoconazole* 100 mg daily Capsule
*Avoid in pregnant women, if there is a risk of pregnancy, and in women who are breastfeeding
Reproduced with kind permission from the British Association of Sexual Health and HIV

Non-albicans species

The majority of VVC cases related to non-albicans species result from C. glabrata, which remains susceptible to available azoles. However, other non-albicans species have high minimum inhibitory concentrations, and C. krusei has intrinsic resistance to fluconazole.1

Longer courses of treatment may be needed for non-albicans infection; 2 weeks is suggested, although there are no data on the optimum duration.1 There is no comparative evidence for different treatments. Suggested treatment alternatives include:1

  • nystatin pessaries—nystatin is the only licensed alternative to azole therapy and is therefore the usual first-line treatment for non-albicans infection
  • amphotericin B vaginal suppositories produced by the local pharmacy at 50 mg once a day for 14 days
  • boric acid vaginal suppositories at 600 mg daily for 2–3 weeks—the dose can be reduced to 300 mg daily if mucosal irritation occurs; however, there is limited evidence for this drug and there may be a teratogenic risk
  • intravaginal flucytosine (5 g cream or 1 g pessary) for 2 weeks either separately or with amphotericin (to reduce the chances of resistance).

Barriers to implementation of the guideline

The guideline authors acknowledge that the diagnosis of VVC is syndromic and that the diagnostic criteria may therefore vary with the clinical setting. Some of the recommended tests (e.g. for precise speciation) may not be available in all settings and some preparations (e.g. flucytosine cream) may not be available on local formularies. In these situations discussions with the local service or pharmacist are likely to be beneficial.


Vulvovaginal candidiasis is a very common, harmless condition that presents to general practice frequently. It can be easily treated with both topical and oral therapies in most cases. Care must be taken to ensure that women are not given treatment for repeat episodes without considering alternative diagnoses or treatment strategies.


View the Guidelines summary of the Clinical Effectiveness Group of the British Association for Sexual Health and HIV on The 2007 United Kingdom national guideline on the management of vulvovaginal candidiasis: egln.co.uk/go/35567


  • Candidiasis is a common disorder and can usually be identified and treated in primary care at low cost to the commissioner
  • Patients will often present to healthcare professionals other than GPs
    (e.g. pharmacists, practice nurses)
  • A simple locally developed diagnosis and treatment pathway identifying treatments of low-acquisition cost could be a useful tool in these circumstances
  • Oral treatments are now available generically (and also without prescription) and can often be cheaper than topical products.
  1. Clinical Effectiveness Group, British Association of Sexual Health and HIV. United Kingdom national guideline on the management of vulvovaginal candidiasis. 2007. Available at: www.bashh.org/documents/1798
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  3. Sobel J. Pathogenesis and epidemiology of vulvovaginal candidiasis. Ann N Y Acad Sci 1988; 544: 547–557.
  4. Lindner J, Plantema F, Hoogkamp-Korstanje J. Quantitative studies of the vaginal flora of healthy women and of obstetric and gynaecological patients. J Med Microbiol 1978; 11 (3): 233–241.
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  8. Bisschop M, Merkus J, Scheygrond H, Van Cutsem J. Co-treatment of the male partner in vaginal candidosis: a double-blind randomized control study. Br J Obstet Gynaecol 1986; 93 (1): 79–81.
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  11. Young G, Jewell D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database Syst Rev 2001; (4): CD000225.
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  16. Duerr A, Heilig C, Meikle S et al. Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: risk and severity. Obstet Gynecol 2003; 101 (3): 548–556.G