What are the medications and doses for treating oral candidiasis?

Medications and Dosages for Oral Candidiasis Treatment

For oral candidiasis, first-line treatment should be based on disease severity, with clotrimazole troches or nystatin for mild disease and fluconazole for moderate to severe cases. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Candidiasis

• First-line options:

  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal tablet: 50 mg applied to mucosal surface over 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: 1-2 pastilles (200,000 U each) 4 times daily for 7-14 days 1

Moderate to Severe Oral Candidiasis

• First-line therapy:
  • Fluconazole: 200 mg on first day, followed by 100-200 mg daily for 7-14 days 1, 2

Fluconazole-Refractory Disease

• First-line options for refractory cases:

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

• Alternative options for refractory cases:

  • Voriconazole: 200 mg twice daily 1
  • Amphotericin B deoxycholate oral suspension: 100 mg/mL 4 times daily 1
  • Intravenous echinocandins (for severe refractory cases):
    • Caspofungin: 70 mg loading dose, then 50 mg daily 1
    • Micafungin: 100 mg daily 1
    • 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 dentures is essential in addition to antifungal therapy 1
• Follow the same medication regimen as for mild oral candidiasis

Recurrent Infections/Chronic Suppressive Therapy

• Fluconazole: 100 mg three times weekly 1, 4
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrence 1

Evidence Quality and Clinical Insights

Fluconazole has demonstrated superior efficacy compared to topical agents like nystatin in clinical trials, particularly in immunocompromised patients 5. In a randomized trial of HIV-infected patients, fluconazole achieved 87% clinical cure rate versus 52% with nystatin, and provided a longer disease-free interval 5.

Clotrimazole troches have shown marked regression of symptoms and mucosal lesions in controlled clinical trials, with significantly better outcomes compared to placebo 6.

For mild cases, topical therapy with clotrimazole or nystatin is generally effective and well-tolerated 7, 8. However, systemic therapy with fluconazole is preferred for moderate to severe cases due to better patient acceptance and higher efficacy 8.

Common Pitfalls to Avoid

• Inadequate treatment duration: Continue treatment for at least 7-14 days, and for at least 2 weeks after symptom resolution to prevent relapse 2
• Failure to address underlying factors: Identify and manage predisposing factors (HIV, diabetes, dentures, immunosuppression)
• Overlooking denture disinfection: For denture-related candidiasis, disinfection of dentures is critical for successful treatment 1
• Delayed switch to alternative therapy: For non-responsive cases after 7-10 days, promptly switch to alternative antifungal agents

Remember that C. glabrata and C. krusei may be less responsive to fluconazole and might require alternative agents or higher doses 4. In immunocompromised patients, particularly those with HIV and CD4 counts <200 cells/μL, more aggressive therapy and longer treatment durations may be necessary 1.