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Treating Thrush

In the UK, the National Institute for Clinical Excellence (NICE) writes clinical guidelines for the treatment of thrush.
NICE's guidelines may work well for acute (one-off) thrush for someone who has had fewer than five or so infections in a lifetime. However there are some flaws in its recommendations for those suffering from repeated thrush infections >5 thrush infections and or those women suffering with vulvodynia.
The problem with the current guidelines is that they haven't been written with the input from vulval dermatologists. They therefore recommend the treatment of drug-resistant thrush with back-to-back pessaries which is in contradiction to the British Association of Dermatologists and the Vulval Pain Society recommendations. Pessaries are not recommended for women suffering with vulvodynia as they are thought to cause further inflammation in the vulva and worsen nerve damage.

What are the guidelines for thrush treatment?

Summary of NICE guidelines (2023 last reviewed)

Advise fluconazole 150 mg oral capsule as a single dose first-line.
Advise clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated.

Severe thrush infection:

Repeat antifungal drug treatment after 72 hours: Prescribe fluconazole 150 mg oral capsule on day 1 and 4 first-line.
Arrange follow-up if symptoms have not resolved within 7–14 days or if symptoms are recurrent.

How should I manage treatment failure of acute vulvovaginal candidiasis?

If a woman has acute vulvovaginal candidiasis which has not responded to initial treatment within 7–14 days:

Arrange an examination of the external genitalia (if not already performed) with high vaginal swab (HVS), and arrange other investigations to assess for an alternative or additional diagnosis, depending on clinical judgement.

For induction, prescribe three doses of oral fluconazole 150 mg (to be taken every 72 hours) first-line.
For maintenance, prescribe oral fluconazole 150 mg once a week for six months first-line.