Vulvovaginal candidiasis is not responding to standard treatment – what should I do?

British Association of Sexual Health and HIV (BASHH) has updated the national vulvovaginal candidiasis guidelinesThis was a significant update highlighting the importance of vulval skin care in the management and prevention of recurrent disease as well as consideration of alternative or dual pathology.

We have compiled responses to the most common GP enquiries below. If you have any other questions, please contact the laboratory via email at mrcm(@) or by phone at 0161 291 5839

In the first instance, a high vaginal swab should be sent for microscopy, and fungal culture and identification. Antifungal susceptibility testing should also be requested. Some yeasts are innately resistant to fluconazole such as Nakaseomyces glabrata (previously Candida glabrata) and Pichia kudriavzevii (previously Candida krusei). If this is the case, recommended treatment are nystatin pessaries or Boric acid vaginal suppositories (available off licence)

If there is no fungal growth, or no clinical improvement after introduction of an antifungal to which the identified isolate is susceptible, it indicates the problem must be elsewhere.  The patient should undergo further investigation, including a complete gynaecological examination, to rule out alternative or additional aetiologies for their symptoms. A large array of dermatological and other conditions can present similarly to and/or concomitantly with VVC such as vulval eczema, lichen sclerosus, vulval atrophy and vulvodynia. It is also useful to keep in mind that topical treatment can cause local irritation, in case of adverse response to treatment.

If the patient responds to treatment but if the symptoms recur repeatedly (at least 4 episodes within 12 months, of which at least 2 have been confirmed by mycology), suppression with once weekly fluconazole for 6 consecutive months should be considered.  The patient should remain asymptomatic whilst on suppression, and any breakthrough symptoms should be fully investigated (examination + HVS). After this, instead of stopping the suppression altogether, extending the time between antifungal doses (once fortnightly in the first instance) and/or timing them with the times the patient would typically flare (normally last 2 weeks of the cycle) should be considered.

The patient needs to be referred to a GUM clinic if the diagnosis is uncertain, treatment is unsuccessful or if the Candida species is resistant to fluconazole (off-label treatment required). Withington Hospital GUM service has special expertise and interest in these patients.

Good daily skin care is the cornerstone in the management and prevention of vulvovaginal candidiasis. There is a lot of over-washing and unnecessary use of feminine and other products. Washing (even with water) dries the skin and dry skin is always itchy. It is also more vulnerable and prone to infection.

Strategies to prevent recurrence include:

  • Use emollient cream (e.g. Doublebase gel, Dermol, E45) at least twice daily and before exercise
  • Avoid vaginal douching and the use of other feminine hygiene products
  • Replace soap with emollient cream for daily genital hygiene
  • Avoid the use of sanitary pads and pantyliners; tampons or menstrual cups are preferred
  • Avoid tight clothes – favour loose and breathable fabrics like cotton
  • Use water-based lubricant during sexual intercourse