Vulvovaginal candidiasis

Author: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. 1997. Updated by Dr Jannet Gomez, April 2017.

What is vulvovaginal candidiasis?

Vulvovaginal candidiasis refers to vaginal and vulval symptoms caused by a yeast, most often Candida albicans. It affects 75% of women on at least one occasion over a lifetime.

Overgrowth of vaginal candida may result in:

Other names used for vulvovaginal candidiasis are  'vaginal thrush’, ‘monilia’, and 'vulvovaginal candidosis'.

What causes vaginal discharge?

Vaginal discharge is a normal process which keeps the mucosal lining of the vagina moist. The amount of vaginal discharge varies according to the menstrual cycle and arousal, and is clear and stringy in the first half of the cycle and whitish and sticky after ovulation. It may dry on underclothes leaving a faint yellowish mark. This type of discharge does not require any medication even when quite profuse, as is often the case in pregnancy. It tends to reduce in amount after menopause.

The most common microorganisms associated with abnormal vaginal discharge are:

Excessive vaginal discharge may also be due to injury, foreign bodies, sexually transmitted infections, and inflammatory vaginitis.

What is the cause of vulvovaginal candidiasis?

Vulvovaginal candidiasis is due to an overgrowth of yeasts within the vagina, most often C albicans. About 20% of non-pregnant women aged 15–55 harbour C albicans in the vagina without any symptoms. 

Oestrogen causes the lining of the vagina to mature and to contain glycogen, a substrate on which C albicans thrives. Symptoms often occur in the second half of the menstrual cycle when there is also more progesterone. Lack of oestrogen makes vulvovaginal candidiasis less common in younger and older postmenopausal women.

Nonalbicans candida species, particularly C glabrata, are observed in 10–20% of women with recurrent vulvovaginal candidiasis.

Who gets vulvovaginal candidiasis?

Vulvovaginal candidiasis is most commonly observed in women the reproductive age group. It is quite uncommon in prepubertal and post menopausal females. It may be associated with the following factors:

What are the symptoms?

Vulvovaginal candidiasis is characterised by:

The rash is thought to be a secondary irritant dermatitis, rather than a primary skin infection.

Symptoms may last just a few hours or persist for days, weeks, or rarely, months, and may be aggravated by sexual intercourse.

See images of vulvovaginal candidiasis ...

How is the diagnosis of vulvovaginal candidiasis made?

The doctor diagnoses the condition by inspecting the affected area and recognising typical clinical appearance.

Swab results can be misleading.

Other tests include culture in Sabouraud chloramphenicol agar or chromagar, the germ tube test, DNA probe testing by PCR, and spectrometry to identify the specific species of candida.

Researchers debate whether non-albicans candida species cause disease or not.  If non-albicans candida is detected, the laboratory can perform sensitivity testing using disc diffusion methods to guide treatment. Sensitivity to fluconazole predicts sensitivity to other oral and topical azoles. C glabrata is often resistant to standard doses of oral and topical azoles.

Treatment of vulvovaginal candidiasis

Appropriate treatment for C albicans infection can be obtained without prescription from a chemist. If the treatment is ineffective or symptoms recur, see your doctor for examination and advice in case symptoms are due to another cause or a different treatment is required.

There are a variety of effective treatments for candidiasis.

Vulvovaginal candidiasis often occurs during pregnancy and can be treated with topical azoles. Oral azoles are best avoided in pregnancy.

Not all genital complaints are due to candida, so if treatment is unsuccessful it may because of another reason for the symptoms.

Recurrent candidiasis

In about 5–10% of women, C albicans infection persists despite adequate conventional therapy. In some women this may be a sign of iron deficiency, diabetes mellitus or an immune problem, and appropriate tests should be done. The subspecies and sensitivity of the yeast should be determined if treatment-resistance arises.

Recurrent symptoms due to vulvovaginal candidiasis are due to persistent infection, rather than re-infection. The aim of treatment is to avoid the overgrowth of candida that leads to symptoms, rather than complete eradication.

The following measures can be helpful.

The following measures have not been shown to help.

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