Candidiasis

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.

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 and swelling of the foreskin in severe cases. 

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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.

Asymptomatic disease does not need treatment.

Any of the available imidazole preparations are effective, either as cream or pessaries. Various preparations (e.g. clotrimazole 10% vaginal cream, 1 applicatorful intravaginally at night) 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.

Avoid local irritants e.g. soaps, bath oils, and vaginal lubricants. 

Vaginal creams and pessaries may weaken latex condoms and diaphragms.

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

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 intraconazole 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 is recurrent can be treated with a 3-7 days course of imidazole cream and/or fluconazole 150mg PO, for 3 doses, 3 days apart, followed by maintenance with fluconazole 100mg PO, weekly for 6 months. An alternative is intraconazole 100mg PO, daily until asymptomatic then 100mg weekly for 6 months.  

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.

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• Thrush (Healthy WA)

Partners do not require treatment unless they are symptomatic.

Patients with recurrent candidiasis require investigation for possible underlying causes such as diabetes mellitus, 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.

This is not a notifiable disease.