Complicated Vulvovaginal Candidiasis

Complicated vulvovaginal candidiasis is candida infection that is severe, recurrent, caused by non-albicans species, or occurring in pregnancy, uncontrolled diabetes or immunosuppression.

• It does not respond to a single dose of fluconazole.
• It needs longer treatment, species identification and correction of risk factors.
• Severe disease includes extensive vulval erythema, oedema, excoriation or fissures.

Intense itching, burning, dyspareunia, dysuria, thick curdy discharge and visible vulval inflammation.

• Marked erythema, oedema, fissures, excoriation, satellite pustules, with disease spreading to the groin and thighs.
• Differential diagnosis: bacterial vaginosis, trichomoniasis, contact dermatitis, lichen sclerosus, herpes genitalis, erythrasma, tinea cruris, psoriasis.
• Complications: secondary bacterial infection, vulval fissuring, chronic vulval pain, recurrence.

Diagnosis needs microscopy and culture with species identification.

• Potassium hydroxide 10 percent microscopy and vaginal culture with species identification.
• Random blood glucose and HbA1c; HIV test; pregnancy test.
• Vaginal pH below 4.5.
• Culture for fluconazole susceptibility when treatment fails.

Give a longer antifungal course than for simple infection, matched to the species.

• Supportive: cotton underwear; avoid irritants; cool compresses; correct diabetes; stop unnecessary antibiotics and steroids.
• Pharmacological: Candida albicans, severe or complicated: fluconazole 150 mg oral on day 1 and day 4 (two doses 72 hours apart), or clotrimazole 100 mg pessary intravaginal nightly for 7 to 14 days. Add clotrimazole 1 percent cream to the vulva twice daily for 7 to 14 days. Non-albicans species (such as Candida glabrata): boric acid 600 mg intravaginal capsule nightly for 14 days, or nystatin 100,000 unit pessary nightly for 14 days. Mild vulval inflammation: hydrocortisone 1 percent cream applied thinly twice daily for up to 5 days in addition to antifungal cream.
• Procedures: none.
• Special groups: in pregnancy use only topical treatment: clotrimazole 100 mg pessary nightly for 7 to 14 days; avoid oral fluconazole and boric acid. In diabetes keep glucose at 6 to 10 mmol/L and use insulin as needed. In HIV infection optimise antiretroviral treatment. In liver impairment avoid repeated oral fluconazole.
• Red flags: failure of treatment after 2 courses, ulceration, white plaque, blood-stained discharge, signs of pelvic infection.
• Follow-up: review at 2 weeks and 4 weeks; repeat culture if symptoms persist; if recurrence occurs, begin maintenance therapy with fluconazole 150 mg oral weekly for 6 months.