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Treating Thrush
Summary
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In the UK, the National Institute for Clinical Excellence (NICE) writes clinical guidelines for the treatment of thrush.
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The problem with the current guidelines is that they haven't been written with the input from vulval dermatologists, largely only with BASSH input. 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.
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BASSH also do not differentiate between 'uncomplicated' and 'complicated' thrush, incorporating strain and susceptibility testing for drug-resistant thrush to prevent severe infections.
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How do BASSH say we should treat thrush?​​​
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Acute:
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First or single isolated presentation of VVC
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Patients typically present with signs and symptoms of acute vulvovaginitis and Candida sp. can be detected by microscopy and/or culture.
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Recurrent:
First or single isolated presentation of VVC
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At least four episodes per 12 months with two episodes confirmed by microscopy or culture when
symptomatic (at least one must be culture)
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Patients with recurrent VVC typically fall into one of two groups depending on response to therapy
with implications for diagnosis and management:
–good or complete response to therapy and asymptomatic between episodes, or
– poor or partial response to therapy with persistence of symptoms between treatments.
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How do CDC approach treating thrush?​​​
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In the USA, the Centre for Disease Control write guidelines for thrush management and suggests the following:
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Uncomplicated VVC Treatment:
Short-course topical formulations (i.e., single dose and regimens of 1–3 days) effectively treat uncomplicated VVC. Treatment with azoles results in relief of symptoms and negative cultures in 80%–90% of patients who complete therapy.​
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Complicated VVC Treatment:
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Vaginal culture or PCR should be obtained from women with complicated VVC to confirm clinical diagnosis and identify non–albicans Candida.
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Recurrent VVC, usually defined as three or more episodes of symptomatic VVC in <1 year.
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If albicans: initial therapy (e.g. a 200mg oral dose of fluconazole every third day for a total of 3 doses [days 1, 4, and 7]). Then Oral fluconazole 200-mg dose weekly for 6 months. ​
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Severe VVC:
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150 mg of fluconazole in two sequential oral doses (second dose 72 hours after initial dose) is recommended.
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Non–albicans Vulvovaginal Candidiasis
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The optimal treatment of non–albicans VVC remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended. If recurrence occurs, 600 mg of boric acid in a gelatin capsule administered vaginally once daily for 3 weeks is indicated. This regimen has clinical and mycologic eradication rates of approximately 70% (1149). If symptoms recur, referral to a specialist is advised.
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ChronicallyYeast.com recommendations:
- Candida glabrata, candida krusei, candida tropicalis - 500mg boric acid pessaries every night for 2 weeks
- Candida parapsilosis – itraconazole 100mg per day orally
- Candida dubliniensis – if susceptible fluconazole long course or boric acid pessaries every night for 2 weeks. ​
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Consider the above information in consultation with your healthcare provider. ​