What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush, 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) are the first-line treatments, with fluconazole (100-200 mg daily for 7-14 days) recommended for moderate to severe cases. 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, 2

  • Instructions: Swish in mouth for as long as possible before swallowing
  • FDA-approved specifically for oral candidiasis 2

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

  • Instructions: Allow to dissolve slowly in mouth

• Clotrimazole troches: 10 mg five times daily for 7-14 days 1, 3

  • Provides sustained antifungal activity in saliva for up to three hours 3

• Miconazole mucoadhesive buccal: 50-mg tablet once daily for 7-14 days 1

Second-Line Treatment Options

For moderate to severe cases or when topical therapy is ineffective:

• Fluconazole: 100-200 mg daily for 7-14 days 1

  • Evidence shows fluconazole is superior to ketoconazole 4
  • Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients 5

• Itraconazole solution: 200 mg/day for refractory cases 1

  • Better absorbed than capsules and comparable in efficacy to fluconazole 4

Treatment Algorithm

1. Assess severity:

   • Mild to moderate: Start with topical therapy (nystatin or clotrimazole)
   • Severe or immunocompromised: Consider systemic therapy (fluconazole)

2. Evaluate response within 3-5 days 1

   • If improving: Complete full 7-14 day course
   • If not improving: Switch to alternative agent or systemic therapy

3. For refractory cases:

   • Extended treatment up to 28 days 1
   • Options include itraconazole solution (200 mg daily), posaconazole suspension, or voriconazole
   • For severe refractory cases: Consider IV echinocandin or amphotericin B 1

Special Considerations

Denture-Related Thrush

• Requires thorough disinfection of dentures in addition to antifungal therapy 1
• Remove dentures at night and clean thoroughly

Immunocompromised Patients

• May require longer treatment durations and maintenance therapy 1
• More rapid relapses may occur with topical therapy than with fluconazole 4
• HIV/AIDS patients may need extended treatment until immune reconstitution 1

Prevention Strategies

• Good oral hygiene practices
• Remove and clean dentures daily
• Rinse mouth after using inhaled corticosteroids
• Control underlying conditions (diabetes, immunosuppression) 1

Comparative Efficacy

Research has demonstrated that miconazole gel is significantly superior to nystatin suspension in immunocompetent infants, with clinical cure rates of 84.7% vs 21.2% by day 5 of treatment 6. However, the most recent guidelines still recommend nystatin as a first-line option for adults 1.

Common Pitfalls

1. Misdiagnosis: Oral thrush can be mistaken for other white lesions, leading to inappropriate treatment 7

2. Inadequate treatment duration: Stopping treatment prematurely can lead to recurrence

3. Ignoring predisposing factors: Failing to address underlying causes (poor oral hygiene, ill-fitting dentures, immunosuppression) 7

4. Resistance development: Though rare, resistance can develop in patients receiving prolonged antifungal therapy, particularly in immunocompromised patients 8

5. Overlooking denture care: In denture wearers, failure to properly disinfect dentures will lead to treatment failure 1