Vulvovaginal candidiasis (VVC) is a syndrome rather than an infection and diagnosis of VVC does not rely on laboratory or clinical criteria alone but a combination of the two. The disease spectrum ranges from “innocent bystander,” where symptoms are wrongly attributed to coincidental isolation of candida to complicated disease where VVC is severe, persistent, or recurrent or there is an underlying host abnormality.¹

Who to test and treat?

Screening is not required for asymptomatic women (evidence level IV, recommendation grade C).^2,3

Episodic VVC

Episodic VVC includes normal women with mild to moderate symptoms and no history of persistent or recurrent symptoms¹ (evidence level IV, recommendation grade C).

Symptoms suggestive of episodic VVC include external dysuria, vulval pruritus, swelling, or redness. Signs include vulval oedema, fissures, excoriation, or thick curdy discharge. The vaginal pH is usually normal^4–9 (evidence level III, recommendation grade B).

• Testing is recommended for episodic VVC whenever possible (evidence level III, recommendation grade B).^4–9

• Treatment is clearly indicated for symptomatic women who are microscopy positive and/or those who are culture positive^4–9 (evidence level III, recommendation grade B).

• Treatment on the basis of symptoms alone is common clinical practice but results in the overtreatment of a large number of women^4–9 (evidence level III, recommendation grade B).

Complicated VVC

This includes severe episodic VVC, persistent non-Candida albicans infection, recurrent VVC, and those with underlying host abnormality—for example, pregnancy, HIV infection and diabetes¹ (evidence level IV, recommendation grade C).

As well as microbiological testing women with chronic symptoms need a careful history and examination. Particular attention needs to be paid to alternative diagnoses, most commonly vulval eczema/dermatitis. Possibilities otherwise include other causes of vaginal discharge—for example, recurrent bacterial vaginosis and also recurrent herpes, vulval vestibulitis syndrome, and other vulvar dermatoses¹⁰ (evidence level III, recommendation grade …