Candidiasis — characterized by a white, odourless, curdy discharge that may be associated with vulval itching and superficial soreness. 

• Optimize management of any underlying conditions causing immunocompromise if possible.
• Advice on self-management measures: –
  • Use simple emollients as a soap substitute to wash and/or moisturize the vulval area.
  • Avoid contact with potentially irritant soap, shampoo, bubble-bath, or shower gels, wipes, and daily or intermenstrual ‘feminine hygiene’ pad products.
  • Avoid vaginal douching.
  • Avoid wearing tight-fitting and/or non-absorbent clothing, which may irritate the area.
  • Avoid use of complementary therapies such as application of yoghurt, topical or oral probiotics, and tea tree or other essential oils.
• Advise fluconazole 150 mg oral capsule as a single dose first-line.
• Advise clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated.

Trichomoniasis — characterized by a fishy-smelling, yellow/green frothy discharge that may be associated with itching, soreness, and dysuria.

• For men and women (not pregnant or breastfeeding): Prescribe oral metronidazole 400 mg twice a day for 5 – 7 days, or metronidazole 2 g as a single oral dose, or tinidazole 2 g as a single oral dose.
• For breastfeeding women and symptomatic pregnant women: Prescribe oral metronidazole 400 mg twice a day for 5–7 days.

Bacterial vaginosis — itch is not usually prominent, and discharge is usually white, homogeneous, and malodorous.

• Prescribe oral metronidazole 400 mg twice a day for 5 to 7 days.
• If the woman prefers topical treatment or cannot tolerate oral metronidazole: Prescribe intravaginal metronidazole gel 0.75% once a day for 5 days (off-label for women aged younger than 18 years) or intravaginal clindamycin cream 2% once a day for 7 days.

Chlamydia — can cause vaginal discharge and dysuria and does not usually present with itch.

• Strongly recommend referral to a genito-urinary medicine (GUM) clinic for management.
• Advise the person that:
  • Their current partner(s) must also be treated for chlamydia to reduce the risk of re-infection and onward transmission.
  • Sexual intercourse (including oral sex) should be avoided until they and their partner(s) have completed treatment (or waited 7 days after treatment with azithromycin).
• Treat the infection for non-pregnant adults and children over the age of 13 years:
  • First-line treatment is doxycycline 100 mg twice daily for 7 days (contraindicated in pregnancy and breastfeeding).
  • If doxycycline is contraindicated or not tolerated consider azithromycin 1 g orally as a single dose for 1 day, followed by 500 mg orally once daily for 2 days.
  • If doxycycline or azithromycin are contraindicated consider erythromycin 500 mg twice daily for 10–14 days.
  • Ofloxacin 200 mg twice daily for 7 days, or 400 mg once daily for 7 days is a possible alternative, but it is contraindicated in pregnancy, children, and growing adolescents.
• For pregnant women — discuss management with other healthcare professionals involved in the woman’s care (such as the woman’s midwife and obstetrician) and GUM
  • Azithromycin, 1 g orally for 1 day, then 500 mg orally once daily for 2 days, or
  • Erythromycin 500 mg four times daily for 7 days, or erythromycin 500 mg twice daily for 14 days, or
  • Amoxicillin 500 mg three times a day for 7 days.

Genital herpes — may present with redness, itch, and ulceration; discharge is uncommon; and acute vulval pain is often the defining symptom.

• Advise on possible self-care measures, such as:
  • Saline bathing — wash the affected area using saline (1 teaspoon salt in 560 ml of warm water) as needed to ease symptoms, promote healing of lesions, and prevent secondary infection.
  • Take over-the-counter analgesia, such as paracetamol or ibuprofen, if needed and there are no contraindications.
  • Consider applying topical petroleum jelly or a topical anaesthetic.
  • Avoid wearing tight clothing, which may irritate lesions
• Advise to abstain from sexual activity (including non-penetrative and oro-genital sex) if lesions are present, until follow-up or until lesions have cleared.
• Advise that transmission can occur when there are no symptoms (‘asymptomatic shedding’), but the risk is higher when a person is symptomatic.
• Advise there is a risk of neonatal transmission if a pregnant woman has a first episode of genital herpes, particularly in the third trimester.
• If the person is unable or unwilling to attend a specialist sexual health service,
  • Advise that oral antiviral treatment should be started within 5 days of the start of a first episode, or while new lesions are forming.
  • Prescribe aciclovir 400 mg three times a day for 5 days, or valaciclovir 500 mg twice a day for 5 days first-line.
  • Prescribe aciclovir 200 mg five times a day for 5 days,or famciclovir 250 mg three times a day for 5 days second-line.
  • Consider extending the duration of treatment for up to 10 days if new lesions appear during treatment or healing is incomplete.
• If the person is immunocompromised or has untreated HIV infection, and genital herpes infection is mild and uncomplicated: Prescribe aciclovir 400 mg five times a day for 7–10 days, or valaciclovir 500–1000 mg twice a day for 10 days, or famciclovir 250–500 mg three times a day for 10 days.