What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush (oral candidiasis), fluconazole 100-200 mg daily for 7-14 days is recommended as the most effective treatment for moderate to severe cases, while topical agents such as clotrimazole troches or nystatin suspension are recommended for mild cases. 1, 2

First-Line Treatment Options

Mild Disease

• Topical agents:
  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days (B-II) 1, 2
  • Nystatin suspension: 100,000 U/mL, 4-6 mL 4 times daily for 7-14 days (B-II) 1, 2
  • Nystatin pastilles: 1-2 pastilles (200,000 U each) 4 times daily for 7-14 days 2
  • Miconazole mucoadhesive buccal tablet: 50 mg applied to mucosal surface once daily for 7-14 days 2

Moderate to Severe Disease

• Oral fluconazole: 100-200 mg (3 mg/kg) daily for 7-14 days (A-I) 1, 2

Treatment of Fluconazole-Refractory Disease

For cases that don't respond to initial fluconazole therapy:

• Itraconazole solution: 200 mg daily for up to 28 days (A-II) 1, 2
• Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days (A-II) 1, 2
• Voriconazole: 200 mg twice daily (B-II) 1, 2
• Amphotericin B oral suspension: 100 mg/mL 4 times daily (B-II) 1, 2
• Intravenous options for severe refractory cases:
  • Echinocandin (e.g., caspofungin, micafungin, anidulafungin) (B-II) 1
  • Amphotericin B deoxycholate: 0.3 mg/kg daily (B-II) 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of dentures is essential in addition to antifungal therapy (B-II) 1, 2
• Remove dentures before performing oral care 2
• Soak dentures for 10 minutes in antimicrobial solution (e.g., chlorhexidine 0.2% if available) 2

Recurrent Infections

• For chronic suppressive therapy: fluconazole 100 mg three times weekly (A-I) 1, 2
• For HIV-infected patients: treatment with antiretroviral therapy is recommended to reduce recurrent infections (A-I) 1

Specific Candida Species

• For C. glabrata infections: oral flucytosine 25 mg/kg 4 times daily for 7-10 days 2
• For C. krusei infections: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 2

Clinical Evidence and Efficacy

Fluconazole has demonstrated superior efficacy compared to topical agents in multiple studies. In a comparative study, fluconazole achieved 100% clinical cure rates compared to only 32% with nystatin suspension 3. Similarly, a single-dose fluconazole 150 mg was shown to be highly effective (96.5% improvement) in palliative care patients 4.

Another study comparing fluconazole tablets to clotrimazole troches found superior clinical cure rates and better patient compliance with fluconazole 5. This is particularly important as compliance affects treatment success.

Practical Administration Tips

• For nystatin suspension: Vigorously swish the solution around the mouth before spitting out 2
• Treatment should continue for at least 48 hours after symptom resolution 2
• Schedule follow-up within 7-10 days to assess response to treatment 2
• Monitor for hepatotoxicity if treatment with azoles extends beyond 7-10 days 2

Prevention Strategies

• Maintain adequate oral hygiene with regular brushing and rinsing 2
• Use a soft toothbrush for oral hygiene 2
• Avoid potential irritants (smoking, alcohol, spicy foods, citrus fruits, hot drinks) 2
• Maintain adequate hydration to keep the mouth moist 2
• Regular dental check-ups 2

By following these evidence-based treatment recommendations, oral thrush can be effectively managed in most patients, with appropriate escalation of therapy for refractory cases.