BNF for Children (BNFC) 2018-2019

Fungal infections

Vaginal fungal infections are not normally a problem in

younger girls but can occur in adolescents.Candidal vulvitis

can be treated locally with cream, but is almost invariably

associated with vaginal infection which should also be

treated.Vaginal candidiasis, rare in girls before puberty, can

be treated with antifungal pessaries or cream inserted high

into the vagina (including during menstruation), however,

these are not recommended for pre-pubertal girls and

treatment with an external cream may be more appropriate.

Single-dose intravaginal preparations offer an advantage

when compliance is a problem. Local irritation can occur on

application of vaginal antifungal products.

Imidazoledrugs (clotrimazole p. 515 , econazole nitrate

p. 515 , fenticonazole nitrate p. 516 , and miconazole p. 516 )

are effective against candida in short courses of 1 to 3 days

according to the preparation used; treatment can be

repeated if initial course fails to control symptoms or if

symptoms recur. Vaginal applications may be supplemented

with antifungal cream for vulvitis and to treat other

superficial sites of infection.

Oral treatment of vaginal infection withfluconazole p. 374

may be considered for girls post-puberty.

Vulvovaginal candidiasis in pregnancy

Vulvovaginal candidiasis is common during pregnancy and

can be treated with vaginal application of an imidazole (such

as clotrimazole), and a topical imidazole cream for vulvitis.

Pregnant women need a longer duration of treatment,

usually about 7 days, to clear the infection. There is limited

absorption of imidazoles from the skin and vagina. Oral

antifungal treatment should be avoided during pregnancy.

Recurrent vulvovaginal candidiasis

Recurrent vulvovaginal candidiasis is very rare in children,

but can occur if there are predisposing factors such as

antibacterial therapy, pregnancy, diabetes mellitus, or

possibly oral contraceptive use. Reservoirs of infection can

also lead to recontamination and should be treated; these

include other skin sites such as the digits, nail beds, and

umbilicus, as well as the gastro-intestinal tract and the

bladder. The sexual partner may also be the source of re-

infection and, if symptomatic, should be treated with a

topical imidazole cream at the same time.

Treatment against candida may need to be extended for

6 months in recurrent vulvovaginal candidiasis.

Other infections

Trichomonal infectionscommonly involve the lower urinary

tract as well as the genital system and need systemic

treatment with metronidazole p. 333 or tinidazole p. 335.

Bacterial infectionswith Gram-negative organisms are

particularly common in association with gynaecological

operations and trauma. Metronidazole is effective against

certain Gram-negative organisms, especiallyBacteroidesspp.

and can be used prophylactically in gynaecological surgery.

Clindamycin below cream and metronidazole gel are

indicated for bacterial vaginosis.

The antiviral drugs aciclovir p. 404 and valaciclovir p. 406

can be used in the treatment of genital infection due to

herpes simplex virus, the HSV type 2 being a major cause of

genital ulceration. They have a beneficial effect on virus

shedding and healing, generally giving relief from pain and

other symptoms.

4.1 Vaginal and vulval infections

4.1a Vaginal and vulval bacterial

infections

ANTIBACTERIALS›LINCOSAMIDES

Clindamycin

lINDICATIONS AND DOSE

DALACIN®2% CREAM

Bacterial vaginosis

▶BY VAGINA

▶Child: 1 applicatorful daily for 3 – 7 nights, dose to be

administered at night

DOSE EQUIVALENCE AND CONVERSION

▶ 1 applicatorful delivers a 5 g dose of clindamycin 2 %.

lUNLICENSED USENot licensed for use in children.

lCAUTIONSAvoid intravaginal preparations (particularly

those that require the use of an applicator) in young girls

who are not sexually active, unless there is no alternative

lINTERACTIONS→Appendix 1 : clindamycin

lSIDE-EFFECTS

▶Common or very commonSkin reactions

▶Frequency not knownConstipation.diarrhoea

(discontinue).dizziness.gastrointestinal discomfort.

headache.increased risk of infection.nausea.vertigo.

vomiting.vulvovaginal irritation

SIDE-EFFECTS, FURTHER INFORMATIONClindamycin 2 %

cream is poorly absorbed into the blood—low risk of

systemic effects.

lCONCEPTION AND CONTRACEPTIONDamages latex

condoms and diaphragms.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines

containing the same drug.

Cream

EXCIPIENTS:May contain Benzyl alcohol, cetostearyl alcohol (including

cetyl and stearyl alcohol), polysorbates, propylene glycol

▶Dalacin(Pfizer Ltd)

Clindamycin (as Clindamycin phosphate) 20 mg per

1 gramDalacin 2 % cream| 40 gramP£ 10. 86 DT = £ 10. 86

ANTIBACTERIALS›NITROIMIDAZOLE

DERIVATIVES

Metronidazole

lDRUG ACTIONMetronidazole is an antimicrobial drug with

high activity against anaerobic bacteria and protozoa.

lINDICATIONS AND DOSE

Bacterial vaginosis

▶BY VAGINA USING VAGINAL GEL

▶Child: 1 applicatorful daily for 5 days, dose to be

administered at night

lUNLICENSED USEMetronidazole vaginal gel not licensed

for use in children under 18 years.

lCAUTIONSAvoid intravaginal preparations (particularly

those that require the use of an applicator) in young girls

who are not sexually active, unless there is no alternative.

not recommended during menstruation.some systemic

absorption may occur with vaginal gel

lINTERACTIONS→Appendix 1 : metronidazole

514 Vaginal and vulval conditions BNFC 2018 – 2019

Genito-urinary system

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