Candidiasis

Organism

Candidiasis is caused predominantly by Candida albicans, although other Candida species can be found.

The incubation period is variable, 2-5 days in infants. The period of communicability is while lesions are present and contact infectivity is unknown.

Clinical presentation

This condition is not considered to be an STI, although male partners can sometimes be secondarily infected. Signs and symptoms vary. Classically, there is thick, curd-like discharge with adherent plaques on the vaginal wall. However, the discharge can be thin and homogeneous, with extensive irritation leading to excoriation of the vulva and perianal region.

In males, there is often a red rash on the glans and under the foreskin (balanitis), which may be itchy.

Investigations

A high vaginal swab with a Gram stain is very sensitive for the diagnosis, with the smear showing hyphae. It is an easy organism to culture. A swab for culture can be taken from the affected area (i.e. vulva or penis). It should be stored and transported at 4–8 °C.

Treatment

Asymptomatic disease does not need treatment.

Standard

Any of the available imidazole preparations are effective, either as cream or pessaries. Various preparations are available for either single dose therapy, or three to seven days of therapy.

Prolonged use should be avoided as contact dermatitis may result.

Where there is severe vulvitis or balanitis associated with candidiasis, one per cent hydrocortisone preparations may be given with antifungal therapy to resolve symptoms. Unopposed steroids may make the condition worse.

Vaginal creams and pessaries may weaken latex condoms and diaphragms.

Oral therapy

Oral therapy should be reserved for resistant or recurrent cases. These are expensive treatments and are no more effective than topical preparations for uncomplicated infections:

  • fluconazole 150 mg orally, as a single dose (not on PBS but available over the counter)
  • ketoconazole* 200 mg orally, 12-hourly with food for five days.

Pregnancy

Topical treatment must be used for 12–14 days in pregnancy because of lower response rates and more frequent relapse. Systemic treatment should be avoided. Both fluconazole and ketoconazole are contraindicated in pregnancy.

Medicines in pregnancy.

Refractory candidiasis

Some strains of candida are more resistant to treatment than others. In cases of refractory candidiasis the fungus should be speciated. Candida glabrata which has failed treatment with imidazoles can be treated with boric acid 600 mg pessaries per vagina (one per night) for two weeks. These need to be manufactured. Seek specialist advice.

* Ketoconazole can cause hepatotoxicity and has important interactions with other drugs.

Related links

Management of partners

Partners do not require treatment unless they are symptomatic.

Follow-up

Patients with recurrent candidiasis require investigation for possible underlying causes such as diabetes, or immunosuppression (including HIV). Other causes of vulvitis such as herpes or dermatitis should also be excluded. The presence of herpetic lesions often makes local conditions favourable for the development of candidiasis.

Candida can be difficult to eradicate, and treatment is not necessary unless there are symptoms. Therefore, regular swabbing is not recommended.

Speciation should be performed if the disease is recurrent or persistent, as resistant Candida may be present. These cases may require referral to a specialist.

Public health issues

This is not a notifiable disease.