What is the treatment for thrush?

Treatment of Thrush

For mild oral thrush, clotrimazole troches 10 mg 5 times daily OR miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7–14 days are the recommended first-line treatments. 1

Treatment Options Based on Severity

Mild Oral Thrush

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

Moderate to Severe Oral Thrush

• Oral fluconazole: 100-200 mg daily for 7-14 days 1, 2
  • This systemic option is preferred for more extensive or severe infections

Fluconazole-Refractory Cases

• Itraconazole solution: 200 mg once 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
• Amphotericin B deoxycholate oral suspension: 100 mg/mL 4 times daily 1

Severe Refractory Cases

• Intravenous echinocandins may be considered: 1
  • Caspofungin: 70-mg loading dose, then 50 mg daily
  • Micafungin: 100 mg daily
  • Anidulafungin: 200-mg loading dose, then 100 mg daily

Treatment for Vaginal Thrush

Uncomplicated Vaginal Thrush

• Topical azoles (clotrimazole, miconazole) for 1-7 days 1
• Single-dose oral fluconazole (150 mg) is an effective alternative 1
• Miconazole vaginal insert (1200 mg) as a one-time dose with external vulvar cream for symptomatic relief 3

Recurrent or Complicated Vaginal Thrush

• Initial therapy: 7-14 days of topical therapy or fluconazole 150 mg repeated 3 days later 1
• Maintenance regimen: Fluconazole 100-150 mg once weekly for 6 months 1
• For non-albicans Candida: Boric acid 600 mg in a gelatin capsule vaginally once daily for 2 weeks 1

Special Considerations

Denture-Related Thrush

• Disinfection of dentures in addition to antifungal therapy is essential 1, 2
• Remove dentures at night and clean thoroughly daily 2
• Consider denture replacement if ill-fitting 2

Immunocompromised Patients

• May require longer treatment duration and systemic therapy 2
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrent infections 1

Pregnancy

• Topical imidazoles are more effective than nystatin for treating vaginal thrush during pregnancy 4
• Treatment for 7 days is more effective than shorter courses during pregnancy 4

Prevention of Recurrence

For Oral Thrush

• Maintain good oral hygiene with regular brushing and flossing 2
• For recurrent infections, fluconazole 100 mg three times weekly can be used as suppressive therapy 1

For Vaginal Thrush

• Wear cotton underwear and loose-fitting clothes 3
• Change out of damp clothes promptly 3
• Avoid unnecessary antibiotics 3
• Control underlying conditions like diabetes 1

Common Pitfalls to Avoid

1. Inadequate treatment duration - Ensure full course completion even if symptoms resolve early
2. Failure to address underlying causes - Identify and manage predisposing factors (diabetes, immunosuppression, antibiotics)
3. Missing non-albicans Candida species - Consider culture for recurrent or refractory cases
4. Neglecting denture hygiene - Proper denture care is crucial for preventing recurrence
5. Drug interactions with azoles - Be cautious with concomitant medications, especially in elderly patients

Thrush is generally responsive to appropriate antifungal therapy, but treatment failure can occur if underlying factors are not addressed or if the causative organism is resistant to the chosen antifungal agent.