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Topical Treatments for Vaginal Infections

Symptoms are most commonly felt on the vulva, but infections usually involve the vagina which should also be treated. Applications to the vulva alone are likely to give only symptomatic relief without cure.

  • Aqueous medicated douches may disturb normal vaginal acidity and bacterial flora.
  • Topical anaesthetic agents give only symptomatic relief and may cause sensitivity reactions.
  • They are indicated only in cases of pruritus where specific local causes have been excluded.

Systemic drugs are required in the treatment of infections such as syphilis and gonorrhoea.
Any patient who potentially has a sexually transmitted disease should have a thorough history and examination. A flowchart for management of the patient with vaginal discharge can be found at the WHO website. Samples should be taken from the vagina and endocervix.

Fungal infections

Candidal vulvovaginitis can be treated locally with cream, but is usually associated with vaginal infection which should also be treated.

  • Vaginal candidiasis is treated primarily with antifungal pessaries or cream inserted high into the vagina. This can take place effectively during menstruation.
  • Single-dose preparations are advantageous when compliance is a problem.
  • Local irritation may occur on application of vaginal antifungal products.

Treatment options

  • Clotrimazole, econazole and miconazole are effective in short courses of 3 to 14 days according to the preparation used.
  • Randomised controlled trials have shown no significant difference between oral or intravaginal imidazole treatment.1,2,3
  • There are fewer systemic side-effects with topical treatment, but more vulval irritation.
  • Vaginal applications may be supplemented with antifungal cream for vulvitis and to treat other superficial sites of infection.
  • Nystatin, one or two pessaries, are inserted for 14 to 28 nights.4
  • A cream is also used in cases of vulvitis and infection of other superficial sites. Nystatin stains clothing yellow.
  • It should be noted that miconazole and econazole have an adverse effect on latex condoms, which could cause condom failure.

Recurrent fungal infection


This is defined as more than 4 episodes per year and can occur in 5% of healthy women.5 This is particularly likely if predisposing factors such as antibacterial therapy, pregnancy or diabetes mellitus are present. The partner may also be the source of re-infection and, if symptomatic, should be treated with cream at the same time.

  • Candida sensitivities may help. Using nystatin vaginally may help.6
  • Treatment against candida may need to be extended for 6 months.
  • Clotrimazole may be given vaginally as a 500 mg single dose pessary every week for 6 months.7

Other applications
  • Vaginal preparations intended to restore normal acidity may prevent recurrence of vaginal infections and permit the re-establishment of the normal vaginal flora. Its effect on latex condoms and diaphragms is not yet known.
  • Topical products containing povidone iodine can be used to treat candidal, trichomonal and non-specific or mixed infections.
  • They are also used for the pre-operative preparation of the vagina.
  • Clindamycin cream and metronidazole gel are also indicated for bacterial vaginosis. Clindamycin damages latex condoms and diaphragms.

Herpes simplex

Aciclovir, famciclovir and valaciclovir may be used in the treatment of genital infection due to herpes simplex virus.

  • They have a beneficial effect on virus shedding and healing, generally giving relief from pain and other symptoms.

Document references
  1. van Heusden AM, Merkus HM, Euser R, et al; A randomized, comparative study of a single oral dose of fluconazole versus a single topical dose of clotrimazole in the treatment of vaginal candidosis among general practitioners and gynaecologists. Eur J Obstet Gynecol Reprod Biol. 1994 Jun 15;55(2):123-7. [abstract]
  2. van Heusden AM, Merkus HM, Corbeij RS, et al; Single-dose oral fluconazole versus single-dose topical miconazole for the treatment of acute vulvovaginal candidosis. Acta Obstet Gynecol Scand. 1990;69(5):417-22. [abstract]
  3. Rohde-Werner H; Topical tioconazole versus systemic ketoconazole treatment of vaginal candidiasis. J Int Med Res. 1984;12(5):298-302. [abstract]
  4. FFPRHC and BASHH Guidance; The management of women of reproductive age attending non-genitourinary medicine settings complaining of vaginal discharge. J Fam Plann Reprod Health Care. 2006 Jan;32(1):33-42; quiz 42.; [As PDF]
  5. Mitchell H; Vaginal discharge - causes, diagnosis, and treatment. BMJ. 2004 May 29;328(7451):1306-8.
  6. Spence D; Candidiasis (vulvovaginal). Clin Evid. 2004 Dec;(12):2493-511.
  7. Clinical Effectiveness Group; National guideline on the management of vulvovaginal candidiasis. (Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Published 2000.
Internet and further reading
  • Health Protection Agency; Management of abnormal Vaginal discharge in women: quick reference guide for primary care. Last updated May 2006.
  • Holmes KK, Mardh PA, Sparling PF, Lemon S, Stamm W, Piot P, et al. Sexually transmitted diseases. 3rd ed. New York: McGraw Hill, 1999
  • British Association for Sexual Health
  • WHO website
Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 429
Document Version: 2
DocRef: bgp25200
Last Updated: 22 Apr 2008
Review Date: 22 Apr 2010




















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