What is the recommended treatment for oral candidiasis?

Treatment of Oral Candidiasis

For oral candidiasis, fluconazole 100-200 mg daily for 7-14 days is recommended for moderate to severe cases, while topical agents such as clotrimazole troches or nystatin suspension are recommended for mild cases. 1

Treatment Algorithm Based on Severity

Mild Oral Candidiasis

• First-line options:
  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 2, 1
  • Miconazole mucoadhesive buccal 50-mg tablet: Applied to mucosal surface over canine fossa once daily for 7-14 days 2, 1
  • Nystatin suspension (100,000 U/mL): 4-6 mL 4 times daily for 7-14 days 2, 1, 3
  • Nystatin pastilles (200,000 U each): 1-2 pastilles 4 times daily for 7-14 days 2, 1

Moderate to Severe Oral Candidiasis

• First-line option:
  • Oral fluconazole: 100-200 mg daily for 7-14 days 2, 1

Fluconazole-Refractory Disease

• Second-line options:
  • Itraconazole solution: 200 mg once daily for up to 28 days 2, 1, 4
  • Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 2, 1
  • Voriconazole: 200 mg twice daily 2, 1
  • Amphotericin B deoxycholate oral suspension 2, 1

Special Considerations

Administration Techniques

• For topical agents:
  • Nystatin suspension should be swished in the mouth for as long as possible before swallowing 1
  • Clotrimazole troches should be allowed to dissolve slowly in the mouth 1, 5
  • Treatment should continue for at least 48 hours after symptom resolution 1

Patient-Specific Factors

• Immunocompromised patients:

  • May require longer treatment duration and closer follow-up 1
  • Systemic therapy (fluconazole) often preferred over topical agents 1, 6
  • HIV/AIDS patients should receive antiretroviral therapy to reduce recurrent infections 1

• Denture wearers:

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

Comparative Effectiveness

• Fluconazole has demonstrated superior efficacy compared to nystatin in clinical trials, with higher cure rates (87% vs. 52%) and lower relapse rates at 28 days (18% vs. 44%) 6
• Itraconazole has shown equivalent results to ketoconazole in treating oropharyngeal candidiasis in AIDS patients 7
• Nystatin and photodynamic therapy are equally effective for clinical remission of denture stomatitis 8

Prevention of Recurrence

• Implement strict oral hygiene measures 1
• For frequent recurrences, chronic suppressive therapy with fluconazole (100-200 mg three times weekly) may be considered 1
• Address underlying conditions that may contribute to persistent infection (diabetes, immunosuppression, recent antibiotic use) 1

Treatment Monitoring

• Schedule follow-up within 7-10 days to assess response to treatment 1
• Monitor for hepatotoxicity if treatment extends beyond 7-10 days with azoles 1
• Consider culture for species identification and resistance patterns if infection is refractory to initial treatment 1

Common Pitfalls to Avoid

• Inadequate treatment duration leading to recurrence
• Failure to address underlying predisposing factors
• Not considering drug interactions with systemic antifungals, especially in elderly patients or those on multiple medications
• Overlooking proper denture care in denture-related candidiasis