What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush (oropharyngeal candidiasis), first-line treatment is topical antifungal therapy with nystatin suspension (100,000 U/mL, 4-6 mL four times daily) or fluconazole 200 mg on day 1 followed by 100-200 mg daily for 7-14 days. 1

First-Line Treatment Options

Topical Antifungal Agents

• Nystatin suspension: 100,000 U/mL, 4-6 mL four times daily for 7-14 days 1

  • Patient instructions: Swish in mouth for as long as possible before swallowing
  • Administer after meals to prolong contact time with affected tissues
  • Continue for at least 48 hours after symptom resolution
  • FDA-approved specifically for oral candidiasis 2

• Nystatin pastilles: 200,000 U each, 1-2 pastilles four times daily for 7-14 days 1

• Clotrimazole troches: 10 mg dissolved in the mouth 5 times daily for 14 days 3

  • Provides concentrations sufficient to inhibit most Candida species for up to three hours

Systemic Antifungal Agents

• Fluconazole: 200 mg on day 1, then 100-200 mg daily for 7-14 days 1
  • Single-dose fluconazole 150 mg has shown 96.5% efficacy in palliative care patients 4
  • Particularly effective for more extensive or recurrent cases
  • In a comparative study with nystatin in infants, fluconazole showed 100% clinical cure rate compared to 32% with nystatin 5

Treatment Algorithm

1. For mild to moderate uncomplicated cases:

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

2. For severe, extensive, or immunocompromised cases:

   • Use systemic fluconazole 200 mg on day 1, then 100-200 mg daily for 7-14 days
   • Consider longer treatment duration (up to 14-21 days) for immunocompromised patients

3. For refractory cases (not responding to first-line therapy):

   • Switch to itraconazole solution 200 mg daily for up to 28 days (effective in 64-80% of fluconazole-refractory cases) 1
   • Alternative: 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

Special Considerations

Denture Wearers

• Remove dentures before using antifungal medication
• Clean dentures thoroughly daily
• Soak dentures for 10 minutes in antimicrobial solution (e.g., chlorhexidine 0.2% if available)
• Consider treating dentures directly with antifungal solution 1

Immunocompromised Patients

• May require longer treatment duration and closer follow-up
• Systemic therapy (fluconazole) often preferred over topical agents
• HIV/AIDS patients should be considered for antiretroviral therapy as additional treatment 1

Recurrent Cases

• Investigate underlying causes (immunosuppression, diabetes)
• Consider fluconazole 100 mg three times weekly for chronic suppressive therapy 1
• Implement strict oral hygiene measures

Prevention Measures

• Maintain good oral hygiene
• Remove and clean dentures daily
• Avoid unnecessary antibiotics when possible
• Regular dental check-ups
• Adequate hydration
• Avoid potential irritants (smoking, alcohol, spicy foods, citrus fruits, hot drinks) 1

Follow-up

• Schedule follow-up within 7-10 days to assess response to treatment
• Monitor for hepatotoxicity if treatment extends beyond 7-10 days with azoles
• If symptoms persist despite appropriate therapy, consider culture to identify resistant species

Treatment of oral thrush is generally highly effective with appropriate antifungal therapy, with most cases resolving within 7-14 days of treatment initiation.