How to manage oral thrush in asthmatic patients on oral steroids (corticosteroids) with a white layer on the tongue and buccal mucosa?

Management of Oral Thrush in Asthmatic Patients on Oral Steroids

Nystatin is the first-line treatment for oral thrush in asthmatic patients on oral corticosteroids, as it effectively treats candidal infection while having minimal systemic absorption and drug interactions.

Diagnosis and Clinical Presentation

• White layer on tongue and buccal mucosa in patients on oral steroids is highly suggestive of oral candidiasis (thrush)
• This is a common side effect of corticosteroid therapy due to local immunosuppression
• Risk factors include:
  • Higher doses of corticosteroids
  • Prolonged treatment duration
  • Poor oral hygiene
  • Lack of proper rinsing after inhaled corticosteroid use

Treatment Options

First-line Treatment: Nystatin

• Nystatin oral suspension 100,000 units four times daily for 7-14 days 1
• Application technique:
  • Patient should swish the suspension in the mouth for 2-3 minutes
  • Then swallow or spit out (depending on whether esophageal involvement is suspected)
  • Avoid eating or drinking for 30 minutes after application
• Benefits:
  • Minimal systemic absorption
  • Few drug interactions
  • Directly targets the site of infection
  • Proven efficacy in treating oral candidiasis in steroid-dependent patients 2

Alternative Options

1. Miconazole oral gel (5-10 ml held in mouth after food four times daily for 7 days) 1

   • Can be used if nystatin is unavailable or not tolerated

2. Fluconazole (oral systemic therapy)

   • Reserved for severe or resistant cases
   • Caution: has significant drug interactions with other medications 3
   • Not first-line due to systemic absorption and potential interactions with asthma medications

3. Ketoconazole (not recommended as first-line)

   • Higher risk of hepatotoxicity
   • More drug interactions than nystatin
   • Not preferred for oral thrush in asthmatic patients

4. Amphotericin B (topical)

   • Can be used as a gargle (1:50 dilution) for treatment of established oral candidiasis 4
   • More commonly used in hospital settings
   • Not typically first-line for outpatient management

Prevention Strategies

• Rinse mouth with water after each use of oral or inhaled corticosteroids 1
• Use spacer devices with inhaled corticosteroids to reduce oropharyngeal deposition 1
• Maintain good oral hygiene
• Consider prophylactic nystatin rinses in high-risk patients (those requiring high-dose or long-term steroids)
• Regular dental check-ups

Special Considerations

• For patients with recurrent thrush despite treatment:

  1. Reassess corticosteroid dose and delivery method
  2. Consider stepping down steroid dose if asthma is well-controlled 1
  3. Evaluate for other immunocompromising conditions
  4. Consider longer duration of antifungal therapy

• For patients with dysphagia or odynophagia:

  • Consider esophageal involvement requiring systemic therapy

Follow-up

• Evaluate response after 7 days of treatment
• If no improvement, consider:
  1. Compliance issues
  2. Resistant Candida species
  3. Alternative diagnosis
  4. Need for systemic therapy

Common Pitfalls

• Failure to address the underlying cause (continued steroid use without preventive measures)
• Inadequate duration of antifungal therapy
• Poor application technique of topical antifungals
• Not recognizing the impact of decreased salivary IgA in patients on inhaled corticosteroids, which contributes to candidiasis susceptibility 5

Remember that oral thrush is a common side effect of steroid therapy that can significantly impact quality of life and medication adherence in asthmatic patients. Prompt and effective treatment with nystatin, combined with preventive measures, can effectively manage this condition while allowing continued asthma control.