Comparisons of mainstream thrush treatment options: What is most effective?

Vulvovaginal candidiasis, also known as thrush, is a yeast infection of the lower female reproductive tract. The infective organism is a fungus, with an estimated 90% of cases caused due to Candida albicans. Other organisms that cause vulvovaginal candidiasis include Candida glabrata, Candida krusei, and Candida parapsilosis.

Treatment options for vulvovaginal candidiasis

Anti-thrush medication is available in a number of formats. These include:

• Pessaries (inserted into the vagina with an applicator)
• Topical creams to deal with Candida on the skin around the entrance to the vagina
• Tablets that are administered orally

Does one work better than the other?

The literature suggests that there is very little difference in both the efficacy and safety of topical and oral azole therapies. They are all considered to have a cure rate in excess of 80% when used to treat acute vaginal and vulval candidiasis (1), with the particular drug choice for a patient usually being based on personal or professional preference and affordability. 

For single episodes of candidiasis, intravaginal antifungal pessaries or an oral antifungal are usually suggested. Where vulval symptoms are present, a topical application is also often considered as a combination. Treatment options are often available as a combination pack (pessary + topical cream).

Topical versus intravaginal creams

A systematic review of topical versus intravaginal creams, undertaken by The Cochrane Collaboration, found that topical creams can cause some additional itching and burning symptoms in the first 48 hours of use (3) – although there is no safety risk in using topical treatments, some patients may opt for an oral treatment to prevent any existing symptoms from being exacerbated.

Condom use. A number of studies have highlighted that a number of vaginal/vulval antifungal treatments such as clotrimazole, fenticonazole, econazole and miconazole may potentially damage latex condoms (4). As such, treatment options from within this group are often prescribed along with advice to abstain from sexual intercourse or use non-latex barrier methods both during and shortly after treatment.

Immunocompromised. Patients who are immunocompromised (particularly those with HIV or diabetes) are advised to take medication for 14 days as opposed to a standard 6-7 day course (7).

Pregnancy. Treatment for pregnant women generally recommends intravaginal clotrimazole or micronazole, with both evidenced to be equally effective as the other over a treatment period of six to seven days (5). 

Oral fluconazole and itraconazole are contraindicated in pregnancy and should never be prescribed(6).

Recurrent vulvovaginal candidiasis (RVVC)

Many women are susceptible to RVVC  with increased use of hormone replacement therapy for menopause. There is is a limited evidence base in regards to the length of treatment for RVVC, but there is some evidence to suggest that 500mg of intravaginal clotrimazole once weekly is effective as a maintenance option (10).

There is also some limited evidence that switching to a progestogen only injectable contraceptive can help relieve symptoms in women who experience RVVC, but the number of studies focused on this area is small and there are a wide range of confounding factors that make it difficult to attribute any improvements or alleviation of symptoms solely to a change in contraceptive (11).

Patients who take orally administered fluconazole and are responsive to it have been evidenced to have a greater chance of remaining disease free during the follow up period than those treated with other antifungal agents (12).

The management of recurrent infections also requires attention to a range of non-pharmaceutical treatments such as using a soap substitute to clean the vulval area, avoiding topical irritants, maintaining general good hygiene, using an emollient to moisturise the vulval skin, and wearing loose fitting underwear.

References

1. Management of vulvovaginal candidiasis (2007) BASHH
2. Odds FC (1988) Candida and Candidosis: A review and bibliography (2nd Ed) Baillierre Tindall: London
3. Watson MC, Grimshaw JM, Bond CM et al (2001) Oral versus intra treatment options for vaginal candidiasis Syst Coch Rev CD002845
4. Candida – female genital (2012) NICE Clinical Knowledge Summary (CKS)
5. Sobel JD (2007) Vulvovaginal candidosis Lancet 369(9577):1961-71
6. Kalkanci A, Guzel AB, Khalil IL et al (2012) Yeast vaginitis during pregnancy: susceptibility testing of 13 antifungal drugs and boric acid detection and the detection of four virulence factors Med Mycol 50(6):585-93
7. Suvirya S, Gandhi R, Agarwal J, Patil R (2015) Erythematous candidiasis leading to systemic manifestations of human immunodeficiency virus co-infection with secondary syphilis: A diagnostic and therapeutic dilemma Eur J Dent 9(3):449-52
8. Sobel JD (2015) Recurrent vulvovaginal candiadiasis Am J Obstret Gyn doi: 10.1016/j.ajog.2015.06.067
9. Marchaim D, Lemanek L, Bheemreddy S, Kaye KS, Sobel JD (2012) Fluconazole-resistant Candida albicans vulvovaginitis J Obs Gyn 120(6):1407-14
10. Sobel JD, Schmitt C, Stein G, Mummaw N, Christensen S, Meriwether C (1994) Initial management of recurrent vulvovaginal candidiasis with oral ketoconazole and topical clotrizamole J Repro Med 39(7):517-20
11. Alves CT, Silva S, Pereira L, Williams DW et al (2014) Effect of progesterone on Candida albicans vaginal pathogenicity Int J Med Micro 304(8):1011-7
12. Albougy HA, Naidoo S (2002) A systematic review of the management of oral candidiasis associated with HIV/AIDS SADJ 57(11):457-466