What is the recommended treatment for oral candidiasis?

Treatment of Oral Candidiasis

The first-line treatment for oral candidiasis is nystatin suspension (100,000 U/mL, 4-6 mL four times daily for 7-14 days) or nystatin pastilles (200,000 U each, 1-2 pastilles four times daily for 7-14 days). 1

First-Line Treatment Options

For mild to moderate oral candidiasis:

• Topical antifungals (preferred for initial therapy):
  • Nystatin suspension: 100,000 U/mL, 4-6 mL four times daily for 7-14 days
    • Instructions: Swish in mouth as long as possible before swallowing
  • Nystatin pastilles: 200,000 U each, 1-2 pastilles four times daily for 7-14 days
    • Instructions: Allow to dissolve slowly in mouth
  • Clotrimazole troches: 10 mg five times daily for 7-14 days
  • Miconazole mucoadhesive buccal: 50-mg tablet once daily for 7-14 days

Second-Line and Severe Cases

For moderate to severe cases or when topical therapy fails:

• Fluconazole: 100-200 mg daily for 7-14 days 1
  • Advantages: Once-daily dosing, high patient acceptance
  • More effective than clotrimazole in eradicating Candida (65% vs 48%) 2
  • Provides more prolonged disease-free state compared to topical treatments 2

Refractory Cases

For fluconazole-refractory disease:

• Itraconazole oral solution: 200 mg once daily for 1-2 weeks 1, 3

  • FDA-approved dosing: 200 mg (20 mL) daily for 1-2 weeks 3
  • For fluconazole-refractory cases: 100 mg (10 mL) twice daily 3
  • Should be vigorously swished in mouth before swallowing 3
  • Take without food if possible for better absorption 3

• Other options for severe refractory cases:

  • Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily
  • Voriconazole: 200 mg twice daily
  • Intravenous echinocandin (e.g., caspofungin)
  • Intravenous amphotericin B deoxycholate (0.3 mg/kg daily)

Special Considerations

Treatment Duration and Assessment

• Standard treatment duration: 7-14 days
• Evaluate clinical response within 3-5 days of treatment initiation
• Continue treatment until clinical resolution of symptoms
• Monitor liver function tests if treatment extends beyond 7-10 days

Denture-Related Thrush

• Requires thorough disinfection of dentures in addition to antifungal therapy
• Remove and clean dentures daily

Immunocompromised Patients

• May require longer treatment durations
• May need maintenance therapy to prevent relapse
• HIV/AIDS patients experience more rapid relapses with topical therapy than with fluconazole

Monitoring and Safety Considerations

• Itraconazole safety concerns:

  • Monitor for signs of hepatotoxicity, especially within the first week 3
  • Watch for neuropathy, hearing loss (can be permanent) 3
  • Numerous drug interactions due to CYP3A4 inhibition 3
  • Use with caution in patients with renal or hepatic impairment 3

• Fluconazole safety:

  • Generally well-tolerated but monitor for elevated liver enzymes 2

Prevention Strategies

• Good oral hygiene practices
• Remove and clean dentures daily
• Rinse mouth after using inhaled corticosteroids
• Avoid unnecessary antibiotics
• Control underlying conditions (diabetes, immunosuppression)

Common Pitfalls to Avoid

1. Failure to identify and address underlying causes (e.g., immunosuppression, diabetes, denture issues)
2. Inadequate treatment duration leading to relapse
3. Not considering drug interactions with systemic antifungals
4. Failure to monitor for adverse effects with systemic treatments
5. Not providing proper instructions for topical treatments (e.g., duration of contact with oral mucosa)
6. Overlooking denture disinfection in denture-related thrush

The most recent evidence supports a stepwise approach, starting with topical treatments for mild cases and progressing to systemic options for more severe or refractory cases, with careful consideration of patient-specific factors and potential adverse effects.