Vaginal thrush is a common infection which is caused by an overgrowth of yeast cells mainly candida albicans. Vaginal thrush tends to have a fast onset.

Symptoms

Symptoms include:

• Itching and soreness of the vagina and vulva

• Redness and swelling of the vaginal area

• Vaginal discharge which is often thick white, cheese-like or sometimes colourless with no smell

• Dysuria (painful urination)

• Superficial dyspareunia (pain at the vaginal opening during intercourse).

Causes

A number of factors may contribute to the development of vaginal thrush such as:

• Diet and emotional wellbeing

• Tight fitting clothing

• Medicines such as broad spectrum antibiotics, contraceptive pill or steroids

• Female hygiene and sanitation

• Irritants (bath products, soap powder or perfume)

• Pregnancy (needs referred)

• Co-morbidity - diabetes, immunosuppression (needs referred)

Who needs referred?

• Patients who fall outside the licensed age range (e.g., Canesten thrush combi isn’t licensed OTC for patients under 16 years old and over 60 years old.)

• Pregnancy/breastfeeding

• Post-menopausal women

• Immunocompromised

• Diabetes mellitus

• First time sufferers

• Suspicion of STD

• Treatment failure (7-14 days following treatment)

• Recurrent infection (>2 episodes in the previous 6 months)

• Suitable treatment option not available OTC

Symptoms requiring referral

• Severe infection

• Offensive smelling/coloured discharge

• Abdominal pain and fever

• Diarrhoea, nausea or vomiting

• Appearance of blood in discharge

• Irregular vaginal bleeding

• Ulcers or blisters on the vagina or vulva

• Lower abdominal pain or dysuria

• Systemic symptoms (e.g., fever)

General advice

• Use a soap substitute to clean the vulval area (don’t use internally or more than once daily)

• Use an emollient to moisturise vulval skin

• Avoid applying topical irritants

• Wear loose-fitting underwear

• Avoid washing underwear in bio washing powder and using fabric conditioners

• Wipe front to back after using the toilet

• Consider using probiotics orally or topically to relieve symptoms (recommended by CKS; although there is no evidence that these are effective, there is no evidence of serious adverse effects)

Treatment options

There are several treatment options:

Clotrimazole 2% cream (16-60 years old)

The cream should be applied thinly 2-3 times daily and rubbed in gently to vulva and surrounding areas for at least 14 days. It should be used as an adjunct to thrush treatment (pessary or capsule).

Clotrimazole 500mg pessary (16-60 years old)

Insert 1 pessary into the vagina once at night as a single dose.

Clotrimazole Combi (pessary & cream) (16-60 years old)

Insert 1 pessary / 10% vaginal cream into the vagina once at night and apply the 2 % cream 2-3 times daily to the vulva and surrounding area.

Clotrimazole 10% intravaginal cream (16-60 years old)

Insert 5 g into the vagina as a single dose at night.

Fluconazole 150mg capsule (16-60 years old)

Take one 150mg capsule immediately as a single dose.

Advice: 

The choice of treatment and formulation will depend on factors such as contraindications and cautions, the licensed age and indication for the product, and the person's preference.

If there are vulval symptoms, consider prescribing a topical imidazolein addition to an oral or intravaginal antifungal.

Fluconazole is teratogenic so sexually active women of childbearing age should ensure they take adequate contraceptive precautions.

Creams and pessaries may damage latex condoms and diaphragms.

The fluconazole 150mg capsule is a systemic medicine compared to all of the other treatments which are topical. Therefore, it is important to check if the patient is on any other medicines which may interact with it. The pessary may be preferred in the case of fluconazole interactions.

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