What is the recommended treatment for oral thrush?

Treatment for Oral Thrush

For oral thrush, fluconazole 100-200 mg daily for 7-14 days is recommended as the first-line treatment for moderate to severe disease, while clotrimazole troches or miconazole buccal tablets are recommended for mild disease. 1

Treatment Algorithm Based on 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 to the mucosal surface over the canine fossa once daily 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
  • Recent evidence suggests a single 150 mg dose of fluconazole may be effective in palliative care patients, with 96.5% showing >50% improvement in signs and symptoms 2

Fluconazole-Refractory Disease

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

Severe Refractory Cases

• Intravenous options:
  • 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 strongly recommended 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 maintenance therapy

Recurrent Oral Thrush

• For patients with recurrent infection, chronic suppressive therapy with fluconazole 100 mg 3 times weekly is recommended 1

Clinical Pearls and Pitfalls

• Important pitfall: Failure to identify and address underlying causes (immunosuppression, antibiotics, inhaled corticosteroids, diabetes) may lead to treatment failure or recurrence
• Caution: Always check for potential drug interactions before prescribing azole antifungals, particularly in patients on multiple medications
• Monitoring: If no improvement after 4 weeks of topical treatment, the diagnosis should be reviewed 3
• Comparative efficacy: Studies have shown fluconazole to be more effective than nystatin for oral thrush, with better patient compliance compared to clotrimazole troches 4, 5
• Treatment duration: Continue treatment for 48 hours after clinical resolution of symptoms to prevent relapse

By following this evidence-based approach to treating oral thrush, clinicians can effectively manage this common condition while minimizing morbidity and improving quality of life for affected patients.