Most Itchy Vulval Conditions Are Due to Thrush

Acute thrush is very common. Everyone has heard of it and it even features in television advertisements for antifungal treatments. However, although it is usually the first thought of patients, pharmacists and even doctors, there are many conditions other than thrush that can cause vulval problems, particularly when it comes to chronic conditions.

For a patient with a long-standing chronic vulvitis, chronic thrush represents the minority (about 20%) of all cases. Many patients tell us that their doctor prescribed antifungal medication without either examining them or taking a vaginal swab.

While it may be acceptable to do this on the first presentation, it is not best practice to use multiple courses of antifungals without confirmation of candidiasis on a vaginal swab. Unfortunately, when a patient has been given multiple courses of topical and/or oral antifungal agents, the false-negative rate of such swabs is very high. Particularly for patients with chronic vulvovaginal candidiasis, the length of time that the patient needs to be withdrawn from such agents before their swab can be recorded as positive again can be very prolonged. We therefore strongly recommend that patients always have a vaginal swab before any treatment is commenced.

Pre-pubertal Children Suffer from Vaginal Thrush

This is completely untrue. Healthy pre-pubertal children who are out of nappies do not suffer from thrush. Thrush may be seen in the setting of chronic maceration (incontinence), immunodeficiency and diabetes.

Thrush requires an oestrogenised environment and is therefore not seen before puberty. In Australia, the only infective vaginitis we see with any frequency is due to group A Streptococcus.

A child with an itchy vulvitis should never be assumed to have thrush, and antifungal creams will not be effective.

Post-menopausal Women Can Suffer from Vaginal Thrush

Adequate oestrogen levels are necessary for a woman to acquire a vaginal candidiasis infection and therefore thrush is not seen in post-menopausal women.

The only exceptions to this rule are:

Probiotics and the Anti-Candida Diet Are the ‘Natural’ Answer for Thrush

This is a very popular concept. The anti-Candida diet is very difficult to comply with and probiotics are expensive. The patients we see have usually tried them without success.

There is no clinical trial that shows that either of these methods is effective. Nevertheless, many patients want to explore ‘natural’ therapy and we respect their right to do so. We are happy to see them again for medical treatment if they have not improved.

Long-term Oral Antifungal Drugs Will Harm Your Liver

The first oral anti-Candida medication available was ketoconazole. This medication did have a real risk of drug-induced hepatitis, in the order of 10%. As a result, all patients on ketoconazole had to have regular liver function tests.

The more recent oral anti-Candida medications recommended in this book, itraconazole and fluconazole, do not have a high risk of liver damage, and our experience with both of these drugs, even when taken long term, is that they have an excellent safety record, similar to the long-term use of antiviral medication.

It is not logical that there is a high rate of acceptance of long-term antiviral medication to control recurrent genital herpes and yet a fear of using oral azoles long-term to control chronic candidiasis.

The main disadvantage of these medications is not liver damage but cost and possible drug interactions, particularly with lipid-lowering statin medication.

Chronic Thrush Can Be Managed by a Weekly Dose of Fluconazole

This is a notion that is widely held because there have been publications that recommend it. Furthermore, it is convenient, as these single doses of fluconazole can be purchased over the counter. It does work for some patients. Nevertheless, we see many failures from this regimen.

We believe that the best way to bring chronic thrush under control initially is with daily oral antifungal treatment. Intermittent regimens are appropriate once control has been achieved, but not before.

If the Antifungal Has Not Worked, Try a Topical Oestrogen

We see many patients who have been prescribed an antifungal cream and when this did not work, a topical oestrogen, both without benefit.

There is only one condition in adults for whom topical oestrogen will have any benefit: oestrogen deficiency. This pertains only to post-menopausal and lactating women.

Topical oestrogens are rapidly effective. If they have not worked in 6 weeks, look for another diagnosis and cease this treatment.

In children, there is only one appropriate condition that should be treated with topical oestrogen and that is fusion of the labia. It is completely inappropriate to use topical oestrogen in a child in any other situation. It will be ineffective and is very likely to sting.

Hormone-replacement Therapy Does Not Cause Thrush or Allergies

This is also completely untrue. We see post-menopausal women who have intractable thrush until they cease their hormone-replacement therapy. In a post-menopausal woman on hormone-replacement therapy who has thrush, it should be assumed that this is responsible.

Furthermore, the thrush will not be easily controllable until the hormone-replacement therapy is temporarily ceased while it is treated with antifungal agents.

With respect to allergies, vaginal creams and pessaries not uncommonly cause an irritant vaginitis, which is reversible when the treatment is ceased.

Many allergic skin reactions to systemic hormone-replacement therapy have been described, and we sometimes see women with similar vaginal allergic reactions to it.

Lichen Sclerosus Can Be Managed Long Term with Once- or Twice-weekly Treatment

There have been many reviews of lichen sclerosus that authoritatively state this. These opinion pieces have been based on a small number of older, short-term research studies, which claimed that it was possible to control the condition using twice-weekly ultra-potent topical corticosteroid. These have now been superseded by our prospective study of lichen sclerosus, which confirms that there is no ‘one size fits all’ treatment for lichen sclerosus. We recommend that treatment be tailored to the individual patient for best results and high levels of long-term control (see Chapter 4).

Lichen Sclerosus Does Not Require Follow-Up

This myth has arisen because active lichen sclerosus may be asymptomatic for long periods of time. Lichen sclerosus probably remits only occasionally.

The majority of patients, if withdrawn from therapy, will eventually have a recurrence of their symptoms, and by the time this happens, there will frequently be more irreversible damage.

Careful follow-up of lichen sclerosus is important in order to:

If a patient’s topical steroid requirements decrease so that they are using only hydrocortisone 1%, a trial of cessation of therapy is reasonable. Try to impress on your patient that, even if they may remain asymptomatic, the disease may reactivate.

If possible, patients should not be entirely discharged from care until they have been objectively disease free for a year. About half of our patients eventually are lost to follow-up. There are probably many reasons for this. We hope their GPs or other doctors are successfully managing them or that they have gone into remission.