What is the treatment for oral thrush (candidiasis)?

Treatment of Oral Thrush (Candidiasis)

For oral thrush (candidiasis), treatment should be tailored to disease severity, with topical antifungals recommended for mild disease and oral fluconazole for moderate to severe cases. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• First-line options:

  • Clotrimazole troches, 10 mg 5 times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal 50-mg tablet applied once daily to the mucosal surface over the canine fossa for 7-14 days 1

• Alternative options:

  • Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days 1
  • Nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily for 7-14 days 1

Moderate to Severe Oral Thrush

• First-line treatment:
  • Oral fluconazole, 100-200 mg daily for 7-14 days 1
  • Clinical response typically occurs within 48-72 hours of initiating therapy 1

Fluconazole-Refractory Disease

1. First alternatives:

   • Itraconazole solution, 200 mg once daily for up to 28 days 1
   • Posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 1

2. Second alternatives:

   • Voriconazole, 200 mg twice daily 1
   • Amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily 1

3. For severe refractory cases:

   • Intravenous echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) 1
   • Intravenous amphotericin B deoxycholate, 0.3 mg/kg daily 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of the denture in addition to antifungal therapy is essential for cure 1
• Remove dentures at night and clean thoroughly

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
• May require longer treatment courses or higher doses

Recurrent Infections

• For patients with frequent recurrences requiring suppressive therapy: fluconazole 100 mg three times weekly 1
• Chronic suppressive therapy is usually unnecessary unless recurrences are frequent or disabling 1

Efficacy Considerations

• Systemic agents (fluconazole) are generally more effective than topical treatments for moderate to severe disease 1, 2
• Single-dose fluconazole 150 mg has shown effectiveness in palliative care patients with oral thrush, with 96.5% showing >50% improvement in symptoms 3
• Topical agents (clotrimazole, nystatin, miconazole) have similar efficacy rates of 73-100% for mild disease 4

Monitoring and Adverse Effects

• Monitor for liver function abnormalities with prolonged azole therapy (>21 days) 5
• Common side effects of azole therapy include nausea, vomiting, diarrhea, and abdominal pain 1
• Potential drug interactions with azoles, particularly with medications metabolized by CYP3A4 5

Clinical Pearls

• Response to therapy is typically rapid, with improvement in signs and symptoms within 48-72 hours 1
• Many individuals have asymptomatic oropharyngeal colonization with Candida species, and treatment may not result in microbiological cure 1
• Itraconazole solution is more effective than itraconazole capsules due to better absorption 1, 5
• When using itraconazole solution, instruct patients to swish vigorously in the mouth for several seconds before swallowing 5
• Taking itraconazole solution under fasted conditions improves systemic availability 5

By following this evidence-based treatment approach based on disease severity, most cases of oral thrush can be effectively managed with excellent outcomes for morbidity, mortality, and quality of life.