What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush, fluconazole is the preferred treatment for moderate to severe cases (200 mg on day 1, then 100 mg daily for 7-14 days), while clotrimazole troches or miconazole buccal tablets are recommended for mild cases in healthy adults. 1

First-Line Treatment Options

Mild Oral Thrush in Healthy Adults:

• Topical antifungals:
  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1, 2
  • Miconazole mucoadhesive buccal tablet: 50 mg applied to the mucosal surface once daily for 7-14 days 1
  • Nystatin suspension: 100,000 U/mL, 4-6 mL 4 times daily for 7-14 days 1, 3
  • Nystatin pastilles: 200,000 U each, 1-2 pastilles 4 times daily for 7-14 days 1

Moderate to Severe Oral Thrush:

• Systemic antifungals:
  • Fluconazole: 200 mg on day 1, then 100 mg daily for 7-14 days 1
  • Single-dose fluconazole 150 mg has shown 96.5% efficacy in palliative care patients with oral thrush 4

Treatment Algorithm Based on Patient Factors

Immunocompetent Adults:

1. Mild cases: Start with topical agents (clotrimazole or nystatin)
2. Moderate to severe cases: Use fluconazole
3. Treatment duration: Continue for at least 14 days and for at least 48 hours after symptom resolution 1

Immunocompromised Patients (HIV/AIDS):

1. Preferred approach: Systemic therapy (fluconazole) rather than topical agents
2. Duration: Longer treatment course with closer follow-up
3. Additional measure: Consider antiretroviral therapy 1

Infants:

• Fluconazole suspension (3 mg/kg once daily for 7 days) has demonstrated superior efficacy (100% cure rate) compared to nystatin suspension (32% cure rate) 5

Recurrent Infections:

• Chronic suppressive therapy with fluconazole 100 mg three times weekly 1

Salvage Therapy for Treatment Failures

If initial treatment fails, consider:

• Itraconazole solution: 200 mg once daily for up to 28 days
• Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days
• Voriconazole: 200 mg twice daily 1

For severe cases where oral administration isn't feasible:

• Intravenous echinocandins (caspofungin, micafungin, or anidulafungin)
• Amphotericin B deoxycholate 1

Prevention Strategies

• Maintain good oral hygiene
• Remove and clean dentures daily
• Avoid unnecessary antibiotics
• For denture wearers: implement strict oral hygiene protocols with chlorhexidine 0.2% solution 1
• Monitor clinical response within 3-5 days of treatment initiation
• Check liver function tests if azole treatment extends beyond 7-10 days 1

Important Clinical Considerations

• Oral thrush can present as white pseudomembranous lesions (thrush) or erythematous candidiasis 6
• C. albicans is the most common causative organism, present in 40-65% of healthy adult mouths 7
• The dorsal surface of the tongue and palatal mucosa beneath maxillary dentures are common reservoir sites 7
• Diagnosis is often confirmed by clinical response to antifungal therapy, but can be enhanced by culturing or microscopic demonstration of fungal hyphae 7

Caution and Pitfalls

• Clotrimazole and ketoconazole can cause liver enzyme changes; monitor liver function when using these medications for extended periods 7
• Fluconazole has demonstrated superior efficacy compared to nystatin in both adults and infants, making it a preferred option when systemic therapy is indicated 4, 5
• Failure to address underlying predisposing factors (dentures, xerostomia, immunosuppression) may lead to treatment failure or recurrence 1, 7