What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush, first-line treatment is fluconazole 100-200 mg daily for 7-14 days for moderate to severe cases, or topical options such as nystatin suspension (400,000-600,000 units four times daily) or clotrimazole troches (10 mg five times daily) for mild cases. 1

First-Line Treatment Options

For Mild Cases:

• Topical antifungal agents:
  • Nystatin suspension: 4-6 mL (400,000-600,000 units) four times daily for 7-14 days 1, 2
    • Administration technique: Place half the dose in each side of the mouth and retain as long as possible before swallowing
  • Nystatin pastilles: 1-2 pastilles (200,000 units each) four times daily for 7-14 days 1
  • Clotrimazole troches: 10 mg five times daily for 7-14 days 3, 1, 4

For Moderate to Severe Cases:

• Systemic antifungal agents:
  • Fluconazole: 100-200 mg daily for 7-14 days 3, 1
    • Note: Single-dose fluconazole 150 mg has shown 96.5% efficacy in palliative care patients, which may be beneficial for reducing pill burden 5
  • Itraconazole oral solution: 200 mg daily for up to 28 days (second-line) 1

Treatment Algorithm Based on Severity and Patient Factors

1. For immunocompetent patients with mild disease:

   • Start with topical agents (nystatin suspension or clotrimazole troches)
   • Continue for 7-14 days or at least 48 hours after symptom resolution

2. For moderate to severe disease or immunocompromised patients:

   • Fluconazole 100-200 mg daily for 7-14 days
   • Consider longer duration for immunocompromised patients

3. For refractory cases:

   • Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily 1
   • Voriconazole: 200 mg twice daily 1
   • Amphotericin B deoxycholate oral suspension: 100 mg/mL four times daily 1
   • Echinocandins for severe refractory cases 1

Comparative Efficacy

Research shows fluconazole has superior efficacy compared to topical agents:

• Fluconazole demonstrated better clinical cure rates than clotrimazole troches in HIV patients 6
• Fluconazole showed 100% cure rate compared to 32% for nystatin in infants with oral thrush 7
• Patient compliance is significantly better with once-daily fluconazole compared to multiple daily doses of topical agents 6

Prevention of Recurrence

• Implement strict oral hygiene measures 1:

  • Brush teeth with soft toothbrush twice daily
  • Clean dentures thoroughly and remove overnight
  • Rinse mouth with alcohol-free mouthwash
  • Maintain adequate hydration

• For denture wearers:

  • Disinfect dentures daily
  • Consider denture replacement if ill-fitting 1

• For patients using inhaled corticosteroids:

  • Rinse mouth thoroughly after each use 1

• For recurrent infections in high-risk patients:

  • Consider chronic suppressive therapy with fluconazole (100-200 mg three times weekly) 1

Special Considerations

• Immunocompromised patients (HIV, cancer, transplant recipients):

  • May require longer treatment duration and closer follow-up
  • Systemic therapy (fluconazole) often preferred over topical agents 1

• Diabetic patients:

  • Ensure adequate glycemic control
  • May require more aggressive treatment 1

• Elderly patients:

  • More susceptible due to physiological changes, comorbidities, and medications 1
  • Monitor for drug interactions with fluconazole

• Patients on multiple medications:

  • Consider single-dose fluconazole 150 mg to reduce pill burden 5
  • Monitor for hepatotoxicity if treatment extends beyond 7-10 days with azoles 1

Remember to confirm diagnosis with clinical examination and consider scraping for microscopic examination (KOH preparation) to confirm yeast forms in uncertain cases 1.