What is the recommended treatment for oral candidiasis?

Treatment of Oral Candidiasis

For oral candidiasis, oral fluconazole 100-200 mg daily for 7-14 days is the recommended first-line systemic treatment, supported by high-quality evidence from the Infectious Diseases Society of America. 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

  • FDA-approved specifically for oral candidiasis
  • Should be swished in the mouth and then swallowed
  • Effective but requires longer duration of use

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

• Miconazole mucoadhesive buccal tablets: 50 mg once daily for 7-14 days 1, 3

  • More comfortable for patients but may have drug interactions

Systemic Antifungal Agents

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

  • Preferred for cases unresponsive to topical therapy
  • Highly effective with strong recommendation and high-quality evidence

• Itraconazole oral solution: 200 mg daily for 7-14 days 1, 4

  • For oropharyngeal candidiasis: 200 mg (20 mL) daily for 1-2 weeks
  • For fluconazole-resistant cases: 100 mg (10 mL) twice daily
  • Should be vigorously swished in the mouth before swallowing
  • Take without food if possible for better absorption

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of infection
   • Check for dentures or other removable oral appliances
   • Assess immune status (HIV, diabetes, immunosuppression)

2. First-line therapy:

   • For mild to moderate cases: Start with topical agents (nystatin or clotrimazole)
   • For moderate to severe cases or immunocompromised patients: Oral fluconazole

3. Refractory cases:

   • Switch to itraconazole solution 200 mg daily or 100 mg twice daily 1, 4
   • Consider posaconazole, voriconazole, or amphotericin B oral suspension 1

4. Severe or resistant cases:

   • Consider echinocandins (micafungin, caspofungin, anidulafungin) for parenteral administration 1, 3

Special Considerations

Denture-Related Candidiasis

• Thorough disinfection of dentures is essential 1
• Remove and clean dentures daily
• Consider soaking dentures in chlorhexidine solution as a disinfectant 5

Immunocompromised Patients

• May require longer treatment durations and maintenance therapy 1
• HIV patients should receive antiretroviral therapy to reduce recurrence 1, 6
• For frequent recurrences, consider suppressive therapy with fluconazole 100 mg daily or 100 mg three times weekly 1

Prevention Strategies

• Maintain good oral hygiene
• Rinse mouth after using inhaled corticosteroids 1
• Avoid unnecessary antibiotics
• Control underlying conditions (diabetes, etc.) 1

Monitoring and Follow-up

• Evaluate clinical response within 3-5 days of treatment initiation 1
• Monitor liver function tests if treatment extends beyond 7-10 days 1
• Be aware that multiple courses of azole therapy increase the risk of developing resistant strains (C. glabrata and C. krusei) 1, 7

Emerging Treatments

• Newer antifungals like isavuconazole show promise for resistant cases 3
• Mouthwashes containing chlorhexidine digluconate, cetylpyridinium chloride, or natural antimicrobials may provide supportive treatment 7