When should I consider referring a patient with vulvovaginal candidiasis for specialist evaluation?

Consider referring a patient with vulvovaginal candidiasis for specialist evaluation if any of the following apply:

• The patient is a young person aged 13–15 years, as prescribing options and management may require specialist input.
• There is diagnostic uncertainty about the condition, necessitating specialist assessment which may include biopsy or special fungal stains to exclude alternative diagnoses.
• Symptoms are not improving and treatment failure is unexplained after appropriate antifungal therapy.
• Symptoms persist after a second course of antifungal treatment.
• A non-albicans Candida species or treatment-resistant Candida is identified, as these may respond poorly to standard antifungal treatments and may require alternative or off-label therapies.
• The patient has uncontrolled diabetes or is otherwise immunocompromised, requiring optimization of underlying conditions and possibly specialist advice.

Referral decisions should be based on clinical judgement and the need for further investigations or alternative management strategies.

This approach aligns with expert opinion and good clinical practice as outlined in UK guidelines.

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