What is the recommended treatment for oral candidiasis using nystatin (antifungal) mouthwash?

Nystatin Mouthwash for Oral Candidiasis Treatment

For mild oral candidiasis, nystatin suspension at a concentration of 100,000 U/mL and a dosage of 4-6 mL 4 times daily for 7-14 days is recommended as an effective treatment option. 1

Treatment Algorithm for Oral Candidiasis

First-Line Treatment Options Based on Disease Severity

Mild Oral Candidiasis:

• Nystatin suspension: 100,000 U/mL, 4-6 mL 4 times daily for 7-14 days 1
• Alternative options:
  • Nystatin pastilles: 200,000 U each, 1-2 pastilles 4 times daily for 7-14 days 1
  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal tablet: 50 mg applied once daily for 7-14 days 1

Moderate to Severe Oral Candidiasis:

• Oral fluconazole: 100-200 mg daily for 7-14 days (more effective than nystatin) 1, 2

Special Considerations

Denture-Related Candidiasis:

• Disinfection of dentures in addition to antifungal therapy 1
• Consider nystatin pastilles (more effective than suspension alone for denture stomatitis) 3

For Fluconazole-Refractory Disease:

1. Itraconazole solution: 200 mg once daily for up to 28 days 1
2. Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
3. Voriconazole: 200 mg twice daily 1

For HIV-Infected Patients:

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
• For recurrent infections: fluconazole 100 mg three times weekly for suppressive therapy 1

Efficacy Considerations

Nystatin works through direct contact with the oral mucosa and is not systemically absorbed, making it safe but requiring strict adherence to administration protocols:

• Administration technique: Instruct patients to swish the suspension thoroughly around the mouth for at least 2 minutes before swallowing or spitting out
• Timing: Use after meals and avoid eating/drinking for 30 minutes after administration
• Duration: Complete the full course even if symptoms improve quickly

Research shows that:

• Fluconazole has higher clinical (87% vs 52%) and mycological cure rates (60% vs 6%) compared to nystatin in HIV patients 2
• Nystatin pastilles may be more effective than suspension alone, with combination therapy showing higher cure rates 3
• Longer treatment duration (4 weeks vs 2 weeks) may improve clinical efficacy for persistent cases 3

Common Pitfalls and Caveats

1. Poor adherence: The four-times-daily dosing of nystatin can lead to poor compliance compared to once-daily fluconazole 4
2. Taste issues: Nystatin suspension has a poor taste that may reduce patient compliance 4, 3
3. Inadequate contact time: Patients may not keep the suspension in contact with oral tissues long enough
4. Incomplete treatment: Stopping therapy when symptoms improve rather than completing the full course
5. Missed diagnosis: Failing to identify and address underlying causes such as:
   • Immunosuppression
   • Diabetes
   • Broad-spectrum antibiotic use
   • Inhaled corticosteroids
   • Poor oral hygiene

Monitoring and Follow-up

• Evaluate clinical response after 7-14 days of treatment
• For persistent symptoms, consider:
  • Culture with susceptibility testing
  • Switching to systemic therapy with fluconazole
  • Extending treatment duration
  • Investigating for underlying immunosuppression

For prophylaxis in high-risk patients (especially those with recurrent infections), nystatin pastilles may help delay the onset of oral candidiasis, particularly in patients with low CD4 counts who carry Candida albicans and have a history of oral candidiasis 5.