What is the treatment for oral thrush?

Treatment of Oral Thrush

Fluconazole 100-200 mg daily for 7-14 days is the recommended first-line treatment for oral thrush, with treatment continuing for at least 48 hours after symptom resolution. 1

First-Line Treatment Options

Systemic Treatment

• Fluconazole:
  • Dosage: 100-200 mg daily for 7-14 days
  • Highly effective with good systemic absorption
  • Single daily dosing improves compliance
  • Clinical studies show 100% cure rates compared to 32% with nystatin in infants 2
  • Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients 3

Topical Treatments (for mild cases)

• Nystatin oral suspension 4:

  • FDA-approved specifically for oral candidiasis
  • Typically administered 4 times daily
  • Less effective than systemic fluconazole but suitable for mild cases

• Clotrimazole troches 5:

  • Mechanism: Inhibits fungal cell membrane permeability
  • Provides localized antifungal effect for up to 3 hours
  • Administered 5 times daily
  • Less convenient than fluconazole but effective for localized disease

Treatment Algorithm

1. Assess severity:

   • Mild localized disease → Consider topical agents
   • Moderate to severe or widespread → Use systemic fluconazole

2. Consider patient factors:

   • Immunocompromised status (HIV/AIDS) → Prefer systemic therapy
   • Denture wearers → Add denture disinfection to treatment plan
   • Medication interactions → Check for potential azole interactions

3. Initial treatment:

   • First choice: Fluconazole 100-200 mg daily for 7-14 days
   • Alternative for mild cases: Clotrimazole troches or nystatin suspension

Alternative Treatments for Refractory Cases

For cases that fail to respond to first-line therapy:

• Itraconazole solution: 200 mg daily for up to 28 days (effective in 64-80% of fluconazole-refractory cases) 1
• Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days (effective in ~75% of refractory cases) 1
• Voriconazole: 200 mg twice daily (note: higher rate of adverse events) 1
• Echinocandins (caspofungin, micafungin, anidulafungin): For severe azole-resistant cases 1
• Amphotericin B oral suspension: Reserved for cases when other options have failed 1

Special Populations

HIV/AIDS Patients

• Consider antiretroviral therapy as adjunctive treatment
• May require longer treatment duration
• Fluconazole 100 mg three times weekly for chronic suppressive therapy in recurrent cases 1

Immunocompromised Patients

• Prefer systemic therapy over topical agents
• Require closer follow-up and potentially longer treatment duration 1

Prevention and Oral Hygiene

Essential adjunctive measures:

• Proper denture care (remove and clean daily)
• Soak dentures in antimicrobial solution for 10 minutes
• Use alcohol-free mouthwash after brushing
• Maintain adequate hydration
• Use soft toothbrush for oral hygiene 1

Monitoring and Follow-up

• Schedule follow-up within 7-10 days to assess response
• Monitor for hepatotoxicity if treatment extends beyond 7-10 days with azoles
• Continue treatment for at least 48 hours after symptom resolution 1

Clinical Pearls and Pitfalls

• Compliance considerations: Studies show significantly better compliance with once-daily fluconazole compared to multiple daily doses of clotrimazole 6
• Resistance concerns: Long-term azole use can lead to resistant Candida strains; use suppressive therapy only when necessary 1
• Diagnostic accuracy: Ensure proper diagnosis with scraping and microscopic examination; consider culture for persistent cases 1
• Denture wearers: Disinfection of dentures is essential in addition to antifungal therapy 1