Fungal infections are more common in pregnancy. Higher circulating oestrogen, altered vaginal flora, and physiological immunosuppression all raise the background rate of vulvovaginal candidiasis, intertrigo in skin folds, and athlete's foot. The pharmacy question is a practical one: which topical antifungals have the most reassuring safety data for use during pregnancy, and which are better avoided?

This article summarises UK guidance from NICE Clinical Knowledge Summaries and the UK Teratology Information Service (UKTIS, published via the BUMPS website) on topical antifungal use in pregnancy, and explains when pharmacy treatment is appropriate and when referral is the safer step.

Vaginal thrush: clotrimazole is first-line

Vulvovaginal candidiasis affects roughly one in five pregnant women at some point during their pregnancy. Clotrimazole pessary or intravaginal cream is the NICE CKS first-line treatment, and UKTIS concludes that topical imidazole antifungals (clotrimazole, miconazole, econazole) have not been shown to increase the risk of congenital anomalies, miscarriage or other adverse pregnancy outcomes in extensive published and observational data.

Practical counter points:

• Use intravaginal treatment, not oral. Oral fluconazole is usually avoided in pregnancy because of a dose-related signal for adverse outcomes; UKTIS and NICE CKS recommend topical treatment instead.
• Treatment duration. A longer course (typically six to seven nights of 100 mg clotrimazole pessary) is usually recommended over the single-dose 500 mg pessary in pregnancy because cure rates at seven days are higher and the longer course is well tolerated.
• Applicators. The external cream can be applied with a finger; some pharmacists advise avoiding an applicator-delivered intravaginal product in the third trimester in favour of manual insertion, consistent with general caution around instrumental vaginal procedures late in pregnancy. Clinical judgement applies.
• Exclude co-existing infection. Vaginal discharge with offensive odour, pelvic pain, abnormal bleeding or fever should be referred for assessment rather than treated as thrush.

Where symptoms persist after a full course, where the diagnosis is uncertain, or where there are red flags, the patient should see their GP or midwife.

Skin fungal infections: miconazole and clotrimazole are standard

For athlete's foot, tinea corporis (ringworm on the body), tinea cruris (groin) and candidal intertrigo in skin folds, topical imidazoles remain the pharmacy counter default. UKTIS concludes that systemic absorption from topical application is minimal and that the available data do not indicate an increased risk of adverse pregnancy outcomes from clotrimazole or miconazole used on the skin.

Practical treatment options:

Short, localised treatment courses are well tolerated. Extensive application over large body surface areas, occluded under dressings, or for prolonged periods goes beyond the self-care scenario and should involve the GP.

Terbinafine: reserve for specific cases

Topical terbinafine 1% cream is effective against dermatophytes. UKTIS notes that published experience of terbinafine in pregnancy is more limited than for clotrimazole or miconazole. Data to date do not indicate a signal for adverse outcomes, but the imidazoles remain the first-line choice where the clinical effect is equivalent. Topical terbinafine may be reasonable where an imidazole has failed, in consultation with the GP.

Oral terbinafine is a different matter: systemic absorption is substantial, and NICE CKS recommends against routine use for dermatophyte infections in pregnancy. Toenail onychomycosis, the classic indication for oral terbinafine, is typically a cosmetic issue that can wait until after delivery and breastfeeding.

What to avoid or refer

• Oral fluconazole (single-dose or short-course) is not recommended in pregnancy at the pharmacy counter. A single 150 mg dose has been associated in some studies with a small increased risk of spontaneous abortion; higher cumulative doses carry a signal for birth defects. Vaginal thrush in pregnancy should be treated topically.
• Oral itraconazole, voriconazole, posaconazole are specialist agents and not relevant to community pharmacy self-care.
• Vaginal thrush persisting after a full topical course, recurrent thrush (four or more episodes in a year), pregnancy-related vaginal bleeding, or suspicion of a non-fungal infection should be referred.
• Suspected tinea capitis (fungal scalp infection) in pregnancy requires oral antifungal prescribing and should not be managed over the counter.

Where the pharmacy fits

Community pharmacy is the first port of call for most uncomplicated fungal infections in pregnancy. The counter conversation should:

• Confirm gestation and any other medications.
• Confirm the indication is one where topical antifungal self-care is reasonable.
• Recommend the first-line topical imidazole at the appropriate course length.
• Explain what would trigger re-presentation (persistence, worsening, red-flag symptoms).
• Document the consultation where the pharmacy has a record-keeping system.

Pharmacy First does not specifically cover thrush or fungal skin infections as conditions with their own PGD, but the routine self-care advice above is consistent with NICE CKS first-line recommendations and is well within the pharmacy scope.

Caveats

This summary reflects UKTIS, NICE CKS and BNF guidance current to April 2026. Individualised care should follow the prescribing clinician, GP or midwife. The absence of a documented increased risk does not mean zero risk — pregnancy prescribing decisions involve weighing benefit and uncertainty.

Sources

• UKTIS / BUMPS — Best Use of Medicines in Pregnancy
• NICE Clinical Knowledge Summaries — Candida (female genital); Fungal skin infection (body and groin); Athlete's foot
• British National Formulary — clotrimazole, miconazole, terbinafine

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