What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush, topical antifungal agents are recommended for mild disease, while oral fluconazole is the treatment of choice for moderate to severe cases. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• Clotrimazole troches, 10 mg 5 times daily for 7-14 days (first-line therapy) 1
• Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days (alternative first-line) 1
• Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days (alternative) 1, 2
• Nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily for 7-14 days (alternative) 1

Moderate to Severe Oral Thrush

• Oral fluconazole, 100-200 mg daily for 7-14 days (first-line therapy) 1
• Treatment duration should be continued until clinical resolution of symptoms 1

Fluconazole-Refractory Disease

• Itraconazole solution, 200 mg once daily for up to 28 days 1
• Posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 1
• Voriconazole, 200 mg twice daily 1
• Amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily 1

For Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole, 400 mg (6 mg/kg) daily 1
• Intravenous echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) 1
• Intravenous amphotericin B deoxycholate, 0.3 mg/kg daily (less preferred alternative) 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of the denture in addition to antifungal therapy is essential for successful treatment 1
• Remove dentures at night and clean thoroughly 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1
• May require longer treatment courses or higher doses of antifungal medications 1
• Single-dose fluconazole may be insufficient; follow standard treatment regimens 3, 4

Recurrent Oral Thrush

• For patients with recurrent infection requiring chronic suppressive therapy, fluconazole 100 mg three times weekly is recommended 1
• Investigate for underlying immunodeficiency or other predisposing factors 5

Evidence Strength and Clinical Pearls

• Fluconazole has demonstrated superior clinical cure rates compared to clotrimazole troches in HIV patients with oral thrush, with better patient compliance due to once-daily dosing 6
• In infants, fluconazole suspension (3 mg/kg daily for 7 days) has shown 100% clinical cure rates compared to only 32% with nystatin suspension 7
• Single-dose fluconazole (150 mg) has shown 96.5% improvement in palliative care patients with oral thrush, offering a convenient option for patients with high pill burden 3
• Treatment-resistant thrush may indicate underlying immunodeficiency or fluconazole-resistant Candida strains and warrants further investigation 5, 4
• Fluconazole resistance is increasingly reported and can lead to treatment failure and progression to invasive candidiasis in immunocompromised patients 4

Monitoring and Follow-up

• Clinical response should be evident within 48-72 hours of initiating therapy 3
• If no improvement after 7-14 days of appropriate therapy, consider fluconazole-resistant Candida species and switch to alternative agents 1, 4
• For denture wearers, ensure proper denture hygiene and fit to prevent recurrence 1