What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush (oral candidiasis), first-line treatment options include topical antifungal agents such as nystatin suspension (100,000 U/mL, 4-6 mL four times daily for 7-14 days) or clotrimazole troches (10 mg five times daily for 7-14 days), with fluconazole (100-200 mg daily for 7-14 days) recommended for moderate to severe cases. 1

First-Line Treatment Options

Mild to Moderate Oral Thrush

• Topical antifungal agents:
  • Nystatin suspension: 100,000 U/mL, 4-6 mL four times daily for 7-14 days 1, 2
  • Nystatin pastilles: 200,000 U each, 1-2 pastilles four times daily for 7-14 days 1
  • Clotrimazole troches: 10 mg five times daily for 7-14 days 1, 3
  • Miconazole mucoadhesive buccal tablet: 50 mg once daily for 7-14 days 1

Moderate to Severe or Refractory Cases

• Systemic antifungal agents:
  • Fluconazole: 100-200 mg daily for 7-14 days 1
  • Single-dose fluconazole: 150 mg (particularly effective in palliative care patients) 4
  • Itraconazole solution: 200 mg daily (for fluconazole-refractory cases) 1

Treatment Algorithm

1. Assess severity:

   • Mild to moderate: Limited white patches, minimal symptoms
   • Severe: Extensive lesions, significant pain, difficulty eating/swallowing

2. Select appropriate treatment:

   • For mild to moderate cases: Start with topical agents (nystatin or clotrimazole)
   • For severe cases or immunocompromised patients: Consider oral fluconazole
   • For patients with difficulty swallowing: Consider fluconazole or itraconazole solution

3. Evaluate response:

   • Clinical response should be evaluated within 3-5 days of treatment initiation 1
   • If no improvement after 5 days, consider switching to a different antifungal agent

4. For refractory cases:

   • Consider extended treatment up to 28 days 1
   • Options include itraconazole solution (200 mg daily), posaconazole suspension, or voriconazole 1
   • In severe refractory cases, intravenous options may be considered 1

Special Considerations

Immunocompromised Patients

• May require longer treatment durations and maintenance therapy 1
• HIV/AIDS patients experience more rapid relapses with topical therapy than with fluconazole 1
• For recurrent infections in immunosuppressed patients, long-term suppressive therapy with fluconazole may be needed 5

Denture-Related Thrush

• Requires thorough disinfection of dentures in addition to antifungal therapy 1
• Remove and clean dentures daily 1

Prevention Strategies

• Maintain good oral hygiene
• Remove and clean dentures daily
• Rinse mouth after using inhaled corticosteroids
• Avoid unnecessary antibiotics
• Control underlying conditions (e.g., diabetes) 1

Evidence Quality and Considerations

Recent evidence strongly supports the efficacy of single-dose fluconazole (150 mg) for oral thrush in palliative care patients, with 96.5% of patients showing more than 50% improvement in signs and symptoms with minimal side effects 4. This approach may be particularly valuable for reducing pill burden in certain patient populations.

While resistance to antifungal agents can develop with prolonged therapy, it appears to be relatively uncommon in clinical practice 6. However, monitoring for treatment response remains important, especially in immunocompromised patients who may be at higher risk for resistant infections.

For pediatric patients, miconazole gel has demonstrated superior efficacy compared to nystatin suspension, with significantly higher cure rates by day 5 of treatment (84.7% vs. 21.2%) 7. This suggests that miconazole gel may be a preferred option for treating oral thrush in children.