Candidiasis

Clinical Features

• vulval itch
• soreness
• vaginal discharge
• superficial dysparaeunia
• external dysuria

Signs

• erythema
• oedema
• discharge (typically curdy and non offensive)
• fissures
• satellite lesions

Diagnosis

• Gram-stained slide from vaginal wall - pseudohyphae or spores seen (detects 65-68%
  symptomatic cases). (If microscopy available)
• High vaginal swab from the anterior fornix
• Consider testing for sexually transmitted infections after a risk assessment

Management
[NB: None in asymptomatic patients – 10-20% women reproductive age have candida present in absence of symptoms)].
Topical and oral agents give 80-90% cure rate in uncomplicated vulvo-vaginal candidiasis in
non-pregnant women. Pregnant women may need longer courses and oral therapy is contraindicated.

Treatment Options 

Advice: avoid soap/use soap substitute

Local skin care (soap substitutes, avoid local irritants/perfume products and tight synthetic clothing as simple self-help measures).

Follow-Up

• Not necessary, unless symptomatic.
• If severe review at 3 to 5 days and consider repeat treatment

Partner notification

Not necessary. No evidence of benefit in treating partners unless they have symptoms of candida themselves

Four or more episodes of symptomatic vaginal candidiasis in 12 months with lab confirmation on at least two occasions 

Prevalence: <5% healthy women of reproductive age with a primary episode will
develop recurrent disease

Management

1. Confirm diagnosis. Ask for 'speciation’ of Candida spp, discuss appropriate tests with the local lab e.g. use the Saboraud agar plates if available in clinic. If this is not available then perform an HVS and let the lab know that you want speciation.
2. Exclude predisposing causes (pregnancy, HIV and other causes of immunosuppression; such as antibiotics, diabetes, oestrogen contraception, corticosteroid use)
3. Local skin care (soap substitutes, avoid local irritants/perfume products and tight synthetic clothing as simple self-help measures).
4. If the client has cyclical symptoms, cyclical antifungal therapy or suppression of the menstrual cycle may be of benefit.
5. Suppressive therapy. Type of preparation and timing of treatment will vary with patient. Regimens are empirical and not based on randomised controlled trials. Principle involves induction (eradication of candida) then maintenance therapy for 6 months. 
   Discuss with a senior doctor before starting therapy.

Examples of Induction and Maintenance Therapies are shown in the Table Below

For advice on severe vulval vaginal candidiasis, candidiasis in diabetics or patients with HIV infection and candidiasis due to non albicans species please refer to BASHH guideline

Symptoms

• Redness of the glans
• Itch and/or irritation of the glans

Diagnosis

• Often over-diagnosed.
• Diagnosis should only be made if yeasts on microscopy or culture.
• Consider other causes of balanitis (see WOS Balanitis Guideline). Take a careful
  dermatological history. Ask about any personal or family history of atopy. Consider topical
  irritant dermatitis eg. use of Savlon cream, other OTC products, excessive salt
• Men frequently present with transient glans erythema occurring a day or so after sex with a
  female partner with vaginal candida (which may be asymptomatic) which does not need
  treated.

Investigations

• Subpreputial swabs for Gram-stain (if available) and culture
• Test for sexually transmitted infections
• Check urine for glucose

Management

• Saline washes if exudative/broken skin
• Otherwise aqueous cream as soap substitute
• Consider clotrimazole (1%) cream twice daily ONLY if yeasts on Gram stain or on
  subsequent culture or clinically indicated
• If underlying cause identified (e.g. diabetes), ensure appropriate follow up with GP/relevant
  specialty

Follow-Up
Only if fails to resolve

United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis (2007) (Accessed online June 2020)