What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush, first-line treatment should be based on disease severity: mild cases should be treated with topical antifungals like clotrimazole troches or miconazole buccal tablets, while moderate to severe cases require oral fluconazole 100-200 mg daily for 7-14 days. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• Clotrimazole troches 10 mg 5 times daily for 7-14 days (strong recommendation; high-quality evidence) 1
• OR miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days (strong recommendation; high-quality evidence) 1
• Alternative options include nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily OR 1-2 nystatin pastilles (200,000 U each) 4 times daily for 7-14 days (strong recommendation; moderate-quality evidence) 1, 2

Moderate to Severe Oral Thrush

• Oral fluconazole 100-200 mg daily for 7-14 days (strong recommendation; high-quality evidence) 1
• Single-dose fluconazole 150 mg has shown efficacy in palliative care patients with oral thrush, with 96.5% of patients showing >50% improvement in signs and symptoms 3

For Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days (strong recommendation; moderate-quality evidence) 1
• Alternatives include voriconazole 200 mg twice daily OR amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily (strong recommendation; moderate-quality evidence) 1, 4
• For severe refractory cases, intravenous options include echinocandins (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) OR intravenous amphotericin B deoxycholate 0.3 mg/kg daily (weak recommendation; moderate-quality evidence) 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of the denture, in addition to antifungal therapy, is strongly recommended (strong recommendation; moderate-quality evidence) 1

Recurrent Infections

• For patients with recurrent infection requiring chronic suppressive therapy, fluconazole 100 mg three times weekly is recommended (strong recommendation; high-quality evidence) 1
• In HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections (strong recommendation; high-quality evidence) 1

Pediatric Considerations

• Fluconazole suspension 3 mg/kg in a single daily dose for 7 days has been shown to be superior to nystatin suspension for treating oral thrush in infants (100% vs 32% clinical cure rate) 5

Clinical Pearls and Pitfalls

• Topical antifungals (clotrimazole, nystatin) are appropriate for mild disease but may be less effective than systemic agents for moderate to severe disease 6
• When using nystatin suspension, instruct patients to swish and hold in mouth for as long as possible before swallowing or spitting 1
• For clotrimazole troches, instruct patients to dissolve slowly in the mouth (approximately 30 minutes) to maximize contact time with the oral mucosa 7
• Fluconazole resistance may develop with prolonged or repeated exposure, particularly in immunocompromised patients 1, 8
• Always consider underlying conditions that may predispose to oral thrush, such as diabetes, immunosuppression, steroid use, or recent antibiotic therapy 1
• In patients with HIV, oral thrush may be an indicator of disease progression and low CD4 counts 1, 6

By following this evidence-based approach to treating oral thrush, clinicians can effectively manage this common condition while minimizing complications and recurrences.