What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush, first-line treatment options include topical nystatin suspension, clotrimazole troches, or systemic fluconazole, with fluconazole showing superior efficacy in most cases. 1

First-Line Treatment Options

Mild to Moderate Cases:

• Topical antifungal agents:
  • Nystatin oral suspension 100,000 U/mL, 4-6 mL four times daily for 7-14 days 1, 2
  • Clotrimazole troches 10 mg, 5 times daily for 7-14 days 1, 3
  • Miconazole mucoadhesive buccal tablet, applied once daily to the mucosal surface for 7-14 days 1

Moderate to Severe Cases:

• Systemic antifungal:
  • Fluconazole 100-200 mg daily for 7-14 days 1
  • Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients 4

Treatment Algorithm

1. Assess severity:

   • Mild (localized white patches): Start with topical therapy
   • Moderate to severe (extensive lesions, pain, difficulty eating): Consider systemic therapy

2. First-line treatment selection:

   • For mild cases: Nystatin suspension or clotrimazole troches
   • For moderate to severe cases: Fluconazole
   • For patients who can't tolerate multiple daily doses: Single-dose fluconazole 150 mg

3. For refractory cases (failure after 14 days of treatment):

   • Itraconazole oral solution 200 mg 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

Evidence Comparison

Fluconazole has demonstrated superior efficacy compared to nystatin in direct comparisons:

• A study in infants showed 100% clinical cure with fluconazole versus only 32% with nystatin suspension (p<0.0001) 5
• Fluconazole offers advantages of once-daily dosing and better systemic distribution 1, 4

Special Considerations

Immunocompromised Patients:

• May require longer treatment duration (14 days minimum)
• Consider prophylactic therapy with fluconazole 100-200 mg three times weekly for recurrent cases 1

Denture Wearers:

• Remove and disinfect dentures daily
• Leave dentures out overnight
• Consider denture replacement if ill-fitting 1

Prevention of Recurrence:

• Maintain good oral hygiene
• Brush teeth with soft toothbrush twice daily
• Clean dentures thoroughly
• Rinse mouth with alcohol-free mouthwash
• Maintain adequate hydration 1

Monitoring

• Schedule follow-up within 7-10 days to assess treatment response
• Monitor for hepatotoxicity if azole treatment extends beyond 7-10 days 1

Pitfalls to Avoid

• Failing to identify and address underlying conditions (diabetes, immunosuppression, recent antibiotic use)
• Not ensuring proper application of topical agents
• Discontinuing treatment prematurely once symptoms improve
• Neglecting denture hygiene in denture wearers
• Missing non-albicans Candida species that may be resistant to standard therapy

By following this evidence-based approach, most cases of oral thrush can be effectively treated with minimal complications and low risk of recurrence.