Vulvovagin*l candidiasis (vagin*l thrush) | DermNet (2024)

What is vulvovagin*l candidiasis?

Vulvovagin*l candidiasis refers to vagin*l and vulval symptoms caused by a yeast, most oftenCandida albicans. It affects 75% of women on at least one occasion over a lifetime.

Overgrowth of vagin*lcandidamay result in:

• White curd-like vagin*l discharge
• Burning sensation in the vagin* and vulva
• An itchy rash on the vulva and surrounding skin.

Other names used for vulvovagin*l candidiasis are 'vagin*l thrush’, ‘monilia’, and 'vulvovagin*l candidosis'.

What causes vagin*l discharge?

vagin*l discharge is a normal process which keeps the mucosal lining of the vagin* moist. The amount of vagin*l discharge varies according to the menstrual cycle and arousal and is clear and stringy in the first half of the cycle and whitish and sticky after ovulation. It may dry on underclothes leaving a faint yellowish mark. This type of discharge does not require any medication even when quite profuse, as is often the case in pregnancy. It tends to reduce in amount after menopause.

The most common microorganisms associated with abnormal vagin*l discharge are:

• Candida albicans and non-albicans candida species
• Trichom*oniasis (due to a small parasite, Trichom*onas vagin*lis); this causes a fishy or offensive odour and a yellow, green or frothy discharge
• Bacterial vaginosis (due to an imbalance of normal bacteria that live in the vagin*); this causes a thin, white/grey discharge and offensive odour.

Excessive vagin*l discharge may also be due to injury, foreign bodies, sexually transmitted infections, and inflammatoryvaginitis.

What is the cause of vulvovagin*l candidiasis?

Vulvovagin*l candidiasis is due to an overgrowth of yeasts within the vagin*, most often C. albicans. About 20% of non-pregnant women aged 15–55 harbour C. albicans in the vagin* without any symptoms.

Oestrogen causes the lining of the vagin* to mature and to contain glycogen, a substrate on whichC. albicans thrives. Symptoms often occur in the second half of the menstrual cycle when there is also more progesterone. Lack of oestrogen makes vulvovagin*l candidiasis less common in younger and older postmenopausal women.

Nonalbicans candida species, particularlyC. glabrata,are observed in 10–20% of women with recurrent vulvovagin*l candidiasis.

Who gets vulvovagin*l candidiasis?

Vulvovagin*l candidiasisis most commonly observed in women in the reproductive age group. It is quite uncommon in prepubertal and postmenopausal females. It may be associated with the following factors:

• Flares just before and during menstruation
• Pregnancy
• Higher dose combined oral contraceptive pill
• Oestrogen-based hormone replacement therapy after the menopause, including vagin*l oestrogen cream
• A course of broad-spectrum antibiotics such as tetracycline or amoxicillin
• Diabetes mellitus
• Obesity
• Iron deficiency anaemia
• Immunodeficiency such asHIV infection
• An underlying skin condition, such as vulvalpsoriasis, lichen planus or lichen sclerosus
• Other illness.

What are the symptoms?

Vulvovagin*l candidiasisis characterised by:

• Itching, soreness and burning discomfort in the vagin* and vulva
• Stinging when passing urine (dysuria)
• Vulval oedema, fissures and excoriations
• Dense white curd or cottage cheese-like vagin*l discharge
• Bright red rash affecting inner and outer parts of the vulva, sometimes spreading widely in the groin to include pubic areas, groin and thighs.

The rash is thought to be a secondaryirritant dermatitis, rather than a primary skin infection.

Symptoms may last just a few hours or persist for days, weeks, or rarely, months, and can be aggravated by sexual intercourse.

• Recurrent vulvovagin*l candidiasis is usually defined as four or more episodes within one year (cyclic vulvovaginitis).
• Chronic, persistent vulvovagin*l candidiasis may lead to lichen simplex — thickened, intensely itchy labia majora (the hair-bearing outer lips of the vulva).

See images of vulvovagin*l candidiasis.

How is the diagnosis of vulvovagin*l candidiasis made?

The doctor diagnoses the condition by inspecting the affected area and recognising a typical clinical appearance.

• The pH of the vagin* tends to be in the normal range (3.8–4.5, ie, acidic), but candida can occur over a wide range of pH.
• The diagnosis is often confirmed by microscopy of a wet mount, vagin*l swab or vagin*l smear, best taken four weeks after earlier treatment.
• In recurrent cases, a swab for culture should be collected after treatment to see whetherC albicans is still present.

Swab results can be misleading and should be repeated if symptoms suggestive of candida infection recur.

• C. albicans can be present without causing symptoms (a false-positive result).
• The yeast can only be cultured when a certain amount is present (a false-negative result).
• Swabs from outside the vagin* can be negative, even when the yeast is present inside the vagin*, and there is a typical rash on the vulva.
• The patient's symptoms may be due to an underlying skin condition such as lichen sclerosus.

Other tests include culture inSabouraud chloramphenicol agar orchromagar, the germ tube test, DNA probe testing by polymerase chain reaction (PCR), and spectrometry to identify the specific species of candida.

Researchers debate whether nonalbicans candida species cause disease or not. If nonalbicans candida is detected, the laboratory can perform sensitivity testing using disc diffusion methods to guide treatment. Sensitivity to fluconazole predicts sensitivity to other oral and topical azoles. C. glabrata is often resistant to standard doses of oral and topical azoles.

What is the treatment of vulvovagin*l candidiasis?

Appropriate treatment forC. albicans infection can be obtained without a prescription from a chemist. If the treatment is ineffective or symptoms recur, see your doctor for examination and advice in case symptoms are due to another cause or a different treatment is required.

There are a variety of effective treatments for candidiasis.

• Topical antifungal pessaries, vagin*l tablets or cream containing clotrimazole or miconazole — one to three days of treatment clears symptoms in up to 90% of women with mild symptoms. Note that oil-based products may weaken latex rubber in condoms and diaphragms.
• Newer formulations include butoconazole and terconazole creams.
• Oral antifungal medicines containing fluconazole or less frequently,itraconazole, may be used ifC albicans infection is severe or recurrent. Note that these drugs may interact with other medicines, particularly statins, causing adverse events.

Vulvovagin*l candidiasis often occurs during pregnancy and can be treated with topical azoles. Oral azoles are best avoided in pregnancy.

Not all genital complaints are due to candida, so if treatment is unsuccessful, it may because of another reason for the symptoms.

Recurrent candidiasis

In about 5–10% of women,C albicans infection persists despite adequate conventional therapy. In some women, this may be a sign of iron deficiency, diabetes mellitus or an immune problem, and appropriate tests should be done. The subspecies and sensitivity of the yeast should be determined if treatment-resistance arises.

Recurrent symptoms due to vulvovagin*l candidiasis are due topersistent infection, rather than re-infection. Treatment aims to avoid the overgrowth of candida that leads to symptoms, rather than complete eradication.

The following measures can be helpful.

• Loose-fitting clothing— avoid occlusive nylon pantyhose.
• Soak in a salt bath. Avoid soap— use a non-soap cleanser or aqueous cream for washing.
• Apply hydrocortisone cream intermittently, to reduce itching and to treat secondary dermatitis of the vulva.
• Treat with an antifungal cream before each menstrual period and before antibiotic therapy to prevent relapse.
• A prolonged course of a topical antifungal agent is occasionally warranted (but these may themselves cause dermatitis or result in the proliferation of non-albicans candida).
• Oral antifungal medication (usuallyfluconazole), which is taken regularly and intermittently (eg, 150–200 mg once a week for six months). The dose and frequency depend on the severity of symptoms. Relapse occurs in 50% of women with recurrent vulvovagin*l candidiasis when they are discontinued, in which case re-treatment may be appropriate. Some women require long-term therapy.
• Oral azoles may require a prescription. In New Zealand, single-dose fluconazole is available over the counter at pharmacies.The manufacturers recommend that fluconazole is avoided in pregnancy.
• Boric acid (boron) 600 mg as a vagin*l suppository at night for two weeks reduces the presence of albicans and non-albicans candida in 70% of treated women. It can be irritating and is toxic, so should be stored safely away from children and animals. Twice-weekly use may prevent recurrent yeast infections. Boric acid should not be used during pregnancy.

The following measures have not been shown to help.

• Treatment of sexual partner— males may get a brief skin reaction on the penis, which clears quickly with antifungal creams. Treating the male doesn't reduce the number of episodes of candidiasis in their female partner.
• Special low-sugar, low-yeast or high-yoghurt diets
• Putting yoghurt into the vagin*
• Probiotics (oral or intravagin*l lactobacillus species)
• Natural remedies and supplements (except boric acid)