BNF for Children 2011-2012

394 7.2.2 Vaginal and vulval infections BNFC 2011–20127 Obstetrics, gynaecology, and urinary-tract disorders7.2.2 Vaginal and vulvalinfectionsEffective specific treatments are available for the commonvaginal infections.Fungal infectionsVaginal fungal infections are not normally a problem inyounger girls but can occur in adolescents. Candidalvulvitis can be treated locally with cream, but is almostinvariably associated with vaginal infection whichshould also be treated. Vaginal candidiasis, rare ingirls before puberty, can be treated with antifungalpessaries or cream inserted high into the vagina (includingduring menstruation), however, these are not recommendedfor pre-pubertal girls and treatment with anexternal cream may be more appropriate. Single-doseintravaginal preparations offer an advantage when complianceis a problem. Local irritation can occur onapplication of vaginal antifungal products.Imidazole drugs (clotrimazole, econazole, fenticonazole,and miconazole) are effective against candida inshort courses of 1 to 3 days according to the preparationused; treatment can be repeated if initial course fails tocontrol symptoms or if symptoms recur. Vaginal applicationsmay be supplemented with antifungal cream forvulvitis and to treat other superficial sites of infection.Oral treatment of vaginal infection with fluconazole(section 5.2.1) may be considered for girls post-puberty.Vulvovaginal candidiasis in pregnancy Vulvovaginalcandidiasis is common during pregnancy and canbe treated with vaginal application of an imidazole (suchas clotrimazole), and a topical imidazole cream forvulvitis. Pregnant women need a longer duration oftreatment, usually about 7 days, to clear the infection.There is limited absorption of imidazoles from the skinand vagina. Oral antifungal treatment should be avoidedduring pregnancy.Recurrent vulvovaginal candidiasis Recurrent vulvovaginalcandidiasis is very rare in children, but canoccur if there are predisposing factors such as antibacterialtherapy, pregnancy, diabetes mellitus, and possiblyoral contraceptive use. Reservoirs of infection canalso lead to recontamination and should be treated;these include other skin sites such as the digits, nailbeds, and umbilicus, as well as the gastro-intestinal tractand the bladder. The sexual partner may also be thesource of re-infection and, if symptomatic, should betreated with a topical imidazole cream at the same time.Treatment against candida may need to be extended for6 months in recurrent vulvovaginal candidiasis. Somerecommended regimens suitable for older children [allunlicensed] include:. initially, fluconazole (section 5.2.1) 150 mg bymouth every 72 hours for 3 doses, then 150 mgonce every week for 6 months;. initially, intravaginal application of a topical imidazolefor 10–14 days, then clotrimazole 500-mgpessary once every week for 6 months.PREPARATIONS FOR VAGINAL ANDVULVAL CANDIDIASISCautions avoid intravaginal preparations (particularlythose that require use of an applicator) in young girlswho are not sexually active, unless there is no alternativePregnancy see notes aboveSide-effects occasional local irritationLicensed use consult product literature for individualpreparationsIndication and doseSee notes above and under preparations belowClotrimazole (Non-proprietary)Cream (topical), clotrimazole 1%, net price 20 g =£1.52, 50 g = £4.12Condoms effect on latex condoms and diaphragms not yet knownDoseApply to anogenital area 2–3 times dailyPessary, clotrimazole 500 mg, net price 1 pessarywith applicator = £3.13DoseInsert 1 pessary at night as a single dose; can be repeatedonce if necessaryCanesten c (Bayer Consumer Care)Cream (topical), clotrimazole 1%, net price 20 g =£2.14; 50 g = £3.50Excipients include benzyl alcohol, cetostearyl alcohol, polysorbatesCondoms damages latex condoms and diaphragmsDoseApply to anogenital area 2–3 times dailyThrush Cream (topical), clotrimazole 2%, net price20 g = £3.99Excipients include benzyl alcohol, cetostearyl alcohol, polysorbatesCondoms damages latex condoms and diaphragmsDoseApply to anogenital area 2–3 times dailyIntravaginal cream (10% VC c ) A, clotrimazole10%, net price 5-g applicator pack = £4.50Excipients include benzyl alcohol, cetostearyl alcohol, polysorbatesCondoms damages latex condoms and diaphragmsDoseInsert 5 g at night as a single dose; may be repeated onceif necessaryNote Brands for sale to the public include Canesten cInternal CreamCream Combi, clotrimazole 10% vaginal cream and2% topical cream, net price 5-g vaginal cream (withapplicator) and 10-g topical cream = £6.81Excipients include benzyl alcohol, cetostearyl alcohol, polysorbatesCondoms damages latex condoms and diaphragmsDoseSee under individual componentsPessaries, clotrimazole 200 mg, 3 pessaries withapplicator = £3.63Condoms damages latex condoms and diaphragmsDoseInsert 200 mg for 3 nights; course may be repeated onceif necessary