Bacterial and fungal vulvo-vaginal infections – how to recognise and manage them

In the third part of our miniseries on vulval health, GP with a special interest in women’s health Dr Louise Clarke discusses bacterial and fungal vulvo-vaginal infections and how they should be managed

Vulvo-vaginal infections are a common presentation in primary care and can cause significant discomfort, distress and embarrassment for patients.

Nurses are often the first point of contact and can play a key role in early recognition, assessment and management of these conditions.

Bacterial and fungal infections of the genital skin frequently present with overlapping symptoms such as redness, itching and discharge, and may be influenced by factors including hygiene practices, hair removal, comorbidities and sexual activity.

This article provides an overview of common bacterial and fungal vulvo-vaginal skin infections, focusing on their presentation, management and the advice to support patients. The fourth article in this series will discuss the key viral vulvo-vaginal skin infections and their management.

Folliculitis

Folliculitis is an inflammation or infection of the hair follicles and is commonly found on the genitalia, although it can occur on any of the hair-bearing areas. It appears as redness and/or pus-filled spots surrounding the hair follicles – the follicles themselves may or may not be visible. Most commonly, folliculitis is caused by a bacterial infection of the superficial hair follicle, but it can also be due to viruses, fungi or non-infectious causes.¹

Pseudofolliculitis is a non-infective cause of red bumps overlying the hair follicles as a result of hair removal techniques.² Trauma from hair removal techniques can also predispose to folliculitis.³ Some folliculitis can arise from exposure to contaminated water, such as in hot tubs or swimming pools.²

Mild cases may resolve without treatment or the use of antiseptics such as chlorhexidine.²More severe cases may require the use of antibiotics or antifungals, depending on the cause. Swabs can be taken from the pus-filled spots and sent to microbiology for analysis.¹

More severe, deeper infections of the hair follicles present as boils or furuncles. These are small, pus-filled abscesses that often respond well to an appropriate antibiotic, such as flucloxacillin, but occasionally require lancing.²

Advice should be given to affected patients to avoid hair removal for at least 3 months, or if this is not possible, to use an electric razor and aim for a stubble length of at least 1mm.²

Tinea cruris

Tinea cruris is a fungal infection that predominantly involves the groin and inner thighs but may extend towards or onto the vulva. The rash is an itchy, red, scaly plaque with a raised edge and central clearing. It can appear as a darkening of skin on darker skin types. Tinea cruris is associated with excessive sweating, obesity, poor hygiene, diabetes and lower socio-economic status. ⁴ Tinea cruris can result from the spread of tinea pedis, a fungal infection of the feet, so it is important to inquire about this in affected patients.⁴

Most cases respond well to a topical antifungal for 4-6 weeks, such as terbinafine or miconazole,⁵ and avoiding tight-fitting clothing should be advised.⁴ Tinea cruris can be spread by skin-to-skin contact and, therefore, can be sexually transmitted.

Candidiasis

Candidiasis (‘thrush’) is the most common cause of vulval and vaginal itching and soreness, and 75% of women will have at least one episode in their lifetime. It causes redness, swelling, and a white curd-like vaginal discharge.⁶ It is more common in pregnancy, diabetes mellitus, immunosuppression and after systemic antibiotics.⁶ Candidiasis is uncommon in prepubertal and postmenopausal age groups.⁷ Sexual intercourse is also a risk factor. Asymptomatic colonisation is common – however, only symptomatic patients should be treated.⁸

Candida can be diagnosed clinically or using swabs sent for microbiology, cultures and sensitivity. However, swabs are unreliable due to the frequency of asymptomatic colonisation or Candida not being present in sufficient quantity to be grown in the lab.⁷

Patients can buy over-the-counter treatments consisting of an anti-fungal pessary, tablet and/or cream, and will have often self-treated prior to presenting to primary care. Use of complementary therapies for thrush are common, such as yoghurt or pro-biotics, but these aren’t recommended. Recurrent cases may require longer courses of oral anti-fungals.⁹

Bacterial Vaginosis (BV)

BV is very common, affecting 20-60% of women worldwide.¹⁰Unlike the other vulvo-vaginal infections above, bacterial vaginosis does not cause itching or soreness. It is asymptomatic in approximately 50% of women. If symptoms do occur, they tend to include thin, grey-white discharge.¹¹ It is caused by an overgrowth of bacteria normally found in the vulvo-vaginal area, the most common being Gardnerella vaginalis.¹⁰

Treatment is with oral and vaginal antibiotics, taken as a single dose or a course. Recurrence is common, with up to 80% of women experiencing recurrence within 9 months. Women with BV are more likely to contract sexually transmitted infections (STIs) but BV is not considered to be an STI despite being more common in sexually active women. In pregnancy, infection with BV leads to higher rates of preterm labour and miscarriage.¹⁰

Sexually Transmitted Infections (STIs)

Chlamydia

Chlamydia is the most common sexually transmitted bacterial infection in the UK, with nearly 170,000 cases diagnosed in 2024.¹² Most cases are asymptomatic, especially in women, with 70% of cases having no symptoms.

When symptoms present, they are commonly vulvo-vaginal, for example:

Change in bleeding pattern – bleeding after sexual intercourse or between periods.
Increased or pus-like discharge.
Pain on sexual intercourse.
Pelvic pain.
Pain on urination.

On examination, there is inflammation or tenderness of the cervix. Chlamydia is treated with antibiotics.¹³

The National Chlamydia Screening Programme aims to reduce complications from untreated chlamydia infections. Chlamydia tests should be proactively offered to women under 25 years old in pharmacies and general practices, as well as sexual health services.¹⁴ As with other STIs, the under-25-year-old age group, those with new or multiple sexual partners and those who don’t use condoms consistently.¹³ STIs also disproportionately affect those from underserved populations, such as alcohol or drug users and those from deprived backgrounds.¹⁵

There is a rarer, more invasive form of chlamydia called Lymphogranuloma venereum, which causes vulval ulcers, bumps and pus-filled lumps along with enlarged lymph nodes. This is uncommon in women in the UK, but regularly occurs in other areas in the world (South and West Africa, India, Southeast Asia, and the Caribbean).¹⁶

Gonorrhoea

Gonorrhoea is another bacterial STI which can be without symptoms in up to 50% of women.¹⁷ It is the second most common bacterial STI after chlamydia.¹⁸ Prevalence in the UK has dropped from an all-time high in 2022, but concerningly antibiotic-resistant cases continue to rise.¹⁹

As with chlamydia, when symptoms present, they are commonly vulvo-vaginal. Most common symptoms include:

A change in bleeding pattern – bleeding after sexual intercourse or between periods
increased or pus-like discharge.
Pain on sexual intercourse.
Pain on urination.

Pelvic and lower abdominal tenderness is less common in gonorrhoea than chlamydia, but it is impossible to distinguish between the two infections on examination alone.¹⁷

Gonorrhoea is also treated with antibiotics, usually a single dose of ceftriaxone intra-muscularly.¹⁷

Syphilis

Syphilis is a sexually transmitted bacterial infection. It can be cured with antibiotics, but if untreated, it can cause severe complications such as neurological and cardiac disease. In women, it most commonly presents as a single, painless vulval ulcer. This ulcer, or chancre, usually appears 9-90 days after initial infection.²⁰

The number of syphilis infections is increasing year on year in the UK. There was a 5% rise in overall infections from 2023 to 2024 alone.¹⁹ The largest increase in syphilis prevalence has been in women who have sex with men (a 203% increase between 2013 and 2023, in England); however, it is still more common in men.²¹

Key points

Bacterial and fungal vulvo-vaginal skin infections are frequently encountered in primary care and require a sensitive and patient-centred approach.
Beyond treatment, education on genital hygiene is an important component of care. Advice on gentle washing with water and emollients, avoiding irritants, tight-fitting underwear and modifying hair removal practices can improve outcomes and prevent repeated infection (see previous article on vulval health here).
In addition, as some genital infections may be transmitted through close skin contact or sexual activity, clinicians can use these consultations as an opportunity to talk to patients about sexual health and signpost to relevant resources – the Brook website is full of patient-friendly information. Women with suspected or confirmed STIs should be signposted to sexual health services.
Advising on contraception, particularly the consistent use of barrier methods, supports both infection control and wider sexual health.

Dr Louise Clarke is a GP in Derbyshire an clinical academic at the University of Nottingham. Dr Clarke is the Treasurer of the British Society for the Study of Vulval Disease (BSSVD)

References

Winters R et al. Folliculitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. [Updated 2023 Aug 8]
Primary Care Dermatology Society. Folliculitis and Boils. Last updated July 2025
Sand F & Thomsen S. (2017). Skin diseases of the vulva: Infectious diseases. Journal of Obstetrics and Gynaecology, 37(7):840–848
Pippin M et al. Tinea Cruris. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. [Updated 2023 Aug 17]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554602/,
Primary Care Dermatology Society. Tinea corporis (body), cruris (groin) and incognito (steroid exacerbated). 2023
Woelber L et al. Vulvar pruritus – causes, diagnosis and therapeutic approach. Dtsch Arztebl Int 2020 Feb 21;116(8):126-133
Vulvovaginal Candidiasis. 2017
Farr A et al. Guideline: Vulvovaginal candidosis (AWMF 015/072, level S2k). Mycoses 2021 Jun;64(6):583-602
NICE CKS. Candida – female genital. Last updated October 2023
Carlson K et al. Bacterial Vaginosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. [Updated 2025 Nov 7]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459216/
NICE CKS. Bacterial Vaginosis. What questions should I ask women with suspected bacterial vaginosis? Last revised July 2023
UK Health Security Agency. Sexually transmitted infections and screening for chlamydia in England: 2024 report. Updated December 2025
NICE CKS. Chlamydia – uncomplicated genital.
National Chlamydia Screening Programme (NCSP). Last updated January 2025
Garcia M et al. Sexually Transmitted Infections. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. [Updated 2024 Apr 20]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560808/
Dermnet NZ. Lymphogranuloma Venereum. 2019
NICE CKS. Gonorrhoea.
Gonorrhoea: guidance, data and analysis.
UKHSA publishes latest STI data: Syphilis cases in England continue to rise. June 2025
NICE CKS. Syphilis. Last revised March 2025
Tracking the syphilis epidemic in England: 2013 to 2023. Updated December 2025