What is the management for a coated tongue suspected to be of fungal origin, such as oral candidiasis?

Management of Oral Candidiasis of Fungal Origin

For oral candidiasis (thrush) suspected to be of fungal origin, fluconazole 200 mg on day 1 followed by 100-200 mg daily for 7-14 days is the recommended first-line treatment for moderate to severe cases, while topical agents such as clotrimazole troches or miconazole buccal tablets are recommended for mild cases. 1, 2

Assessment and Treatment Selection Based on Severity

Mild Disease

• First-line options (choose one):

  • Clotrimazole troches 10 mg 5 times daily for 7-14 days 2, 1
  • Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 2, 1

• Alternative options (if first-line not available/tolerated):

  • Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days 2
  • Nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily for 7-14 days 2

Moderate to Severe Disease

• First-line treatment:
  • Oral fluconazole 200 mg on first day, followed by 100-200 mg daily for 7-14 days 2, 1, 3
  • Continue treatment until at least 48 hours after symptom resolution 1

Management of Fluconazole-Refractory Disease

If no improvement after 7 days of fluconazole treatment:

1. Second-line options (choose one):

   • Itraconazole solution 200 mg once daily for up to 28 days 2, 4
   • Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 2
   • Voriconazole 200 mg twice daily 2

2. For severe refractory cases:

   • Intravenous echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) 2
   • Amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily 2

Special Considerations

Immunocompromised Patients

• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrent infections 2
• May require longer treatment duration and closer follow-up 1
• Systemic therapy (fluconazole) generally preferred over topical agents 1

For Recurrent Infections

• Identify and address underlying predisposing factors (xerostomia, dentures, diabetes, immunosuppression) 5, 6
• Consider chronic suppressive therapy with fluconazole 100 mg three times weekly for patients with recurrent infections 2, 1

Prevention Strategies

• Maintain good oral hygiene
• Remove and clean dentures daily
• Avoid unnecessary antibiotics when possible
• For denture stomatitis, disinfect dentures with chlorhexidine solution 7

Monitoring Response

• Improvement typically occurs within 48-72 hours
• Complete resolution usually occurs within 7-14 days
• Monitor liver function tests if azole treatment extends beyond 7-10 days 1
• If no improvement is seen after 7 days, consider:
  • Alternative diagnoses
  • Resistant Candida species
  • Need for longer treatment duration
  • Alternative antifungal agents

Common Pitfalls to Avoid

1. Failing to identify and address underlying predisposing factors
2. Insufficient treatment duration (should continue for at least 48 hours after symptom resolution)
3. Not considering drug interactions with azole antifungals
4. Overlooking the need for denture hygiene in denture wearers
5. Not recognizing fluconazole-resistant species (particularly C. glabrata) that require alternative treatment 2