Recurrent thrush- spotting the pattern

It’s a busy Thursday morning. You scan down your clinic list, heart sinking a little at the back-to-back complexity of the cases ahead and wondering how late you might run by the end (hands up -frequent offender!). Then you clock a telephone appointment with Sarah. She is a 28-year-old lady seeking treatment for ‘thrush’. 

You pick up the phone. She reports she’s had thrush before, symptoms seem the same, she feels ‘sure it is thrush’. 

Excellent! A quick prescription for fluconazole and done! Maybe you might even make it to coffee on time….

However, are we doing Sarah justice here? Should we be happy to prescribe based on Sarah’s self-diagnosis? When does acute vulvovaginitis become recurrent vulvovaginitis, and does why it matter? 

As a reminder, BASHH guidelines draw a distinction between ‘acute’ vulvovaginal candidiasis (VVC) and ‘recurrent’ vulvovaginal candidiasis. Acute VVC is defined as a ‘first or single isolated presentation of VVC’. Recurrent VVC is defined as ‘at least four episodes per 12 months with two episodes confirmed by microscopy or culture when symptomatic (at least one must be culture)’. Recommended first line treatment for acute VVC involves stat doses of oral fluconazole (clotrimazole pessary second line if fluconazole contraindicated), whereas treatment of recurrent VVC involves a much more protracted 6-month course of treatment.                                                                                                                                    

Given the significant divergence of treatment, identifying recurrent VVC is key.

Previous studies have shown patient dissatisfaction with the route to diagnosis of recurrent thrush, with perceived diagnostic delay. A recent article from the BJGP explored patient and clinician perspectives on the diagnostic process for recurrent thrush in primary care, highlighting potential pitfalls, sources of patient frustration, and opportunities to improve care. 

This was a qualitative study including 32 patients who ‘self-identified’ as having recurrent thrush (22 reported at least 1 positive swab for Candida Albicans, 2 for an alternative species, 2 tested negative and 6 stated no swabs had been taken), and 25 health care professionals (mix of primary care and sexual health clinicians). 

History

One of the key themes highlighted was the challenge of recognising patterns of recurrence. Patients may have self-treated with OTC medications multiple times before seeking medical care. Patients expressed hesitancy about volunteering a history of previous episodes, with some waiting to be asked and others unsure of how to share that information. Therefore, recurrent VVC may appear as acute VVC unless the patient 

is explicitly asked about the frequency and duration of any previous episodes. 

Clinicians reported that as VVC is commonly acute, it can be easy to miss cases when it has become recurrent. They also suggested that the system of accessing care from multiple different clinicians/ providers could feed into difficulty identifying patterns of recurrence.

Examination

Patients reported variation in examination, with some reporting that they had never been examined. Some were unsure if it was needed and therefore felt like they could not ask for this if it was not offered. There were reports of diagnosis being based on description of symptoms alone.

Testing

As above, the BASHH guidelines require 2 swabs confirming Candida in order to diagnosis recurrent VVC, but acute thrush may be treated empirically based on reported symptoms in primary care. Clinicians reported that delayed recognition of when VVC became recurrent was a key source of delay in investigation:

‘You only swab if the symptoms recur, and that’s fine if this is a first-ever episode, but if what you get is fragmented care and people keep saying, ‘We don’t swab because it’s a first episode,’ you don’t join the dots and realise it’s the fifth episode.’

Patients expressed difficulty accessing testing in a timely manner, describing resorting to self-treatment prior to appointments due intolerable symptoms. Some also expressed frustration at repeated requests for swabs.

So, what are the take home messages?

Recognition of when acute VVC becomes recurrent VVC is important, enabling appropriate investigation and treatment. However, it can be easy to miss. Be aware that patients may have self-managed multiple episodes of VVC prior to their first presentation to primary care. We should ask Sarah how many episodes of suspected thrush she has had in the last year, and if symptoms resolve between episodes. Examination is vital in recurrent presentations-remember not all vulvovaginal itch is thrush!  As outlined in a practical and helpful BJGP article, vulval lichen sclerosus is a key differential that is frequently missed due to a lack of examination (note most common in pre-pubertal and post-menopausal patients, but can present at any age).

For those undergoing investigation for suspected recurrent VVC, encourage them not to self-treat before testing, explain how this may affect results, and consider offering self-swabs to keep at home to facilitate prompt testing when next symptomatic. Finally, don’t forget the importance of clear communication. Even if there are no delays, reaching the diagnosis of recurrent VVC necessarily takes time. Explaining the criteria may enable patients to understand the request for repeated swabs and could help mitigate frustration!