Treatment of Oral Thrush (Candidiasis)
For oral thrush (oropharyngeal candidiasis), oral fluconazole 100-200 mg daily for 7-14 days is strongly recommended as the most effective treatment. 1, 2
First-line Treatment Options
Mild Oral Thrush
- Clotrimazole troches (10 mg 5 times daily for 7-14 days) 2, 1
- Nystatin suspension (100,000 U/mL, 4-6 mL four times daily) or pastilles (200,000 U, 1-2 pastilles 4-5 times daily) for 7-14 days 2, 1
- Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
Moderate to Severe Oral Thrush
- Oral fluconazole 100-200 mg daily for 7-14 days (preferred systemic therapy) 2, 1
- For patients who cannot tolerate oral therapy, intravenous fluconazole 400 mg (6 mg/kg) daily is recommended 2
- Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients with oral thrush 3
Treatment for Fluconazole-Refractory Cases
- Itraconazole oral solution 200 mg daily for 7-14 days (64-80% response rate) 2, 4
- For patients responding to itraconazole, clinical response typically occurs within 2-4 weeks 4
- For patients unresponsive to fluconazole, itraconazole 100 mg twice daily is recommended 4
- Voriconazole 200 mg twice daily (oral or IV) for 14-21 days 2
- Posaconazole suspension 400 mg twice daily (approximately 75% efficacy in refractory cases) 2
Alternative Therapies for Refractory Cases
- Echinocandins (for severe refractory cases):
- Micafungin: 150 mg daily
- Caspofungin: 70-mg loading dose, then 50 mg daily
- Anidulafungin: 200 mg daily 2
- Amphotericin B deoxycholate 0.3-0.7 mg/kg daily (less preferred alternative) 2
Special Considerations
Denture-Related Thrush
- Proper denture hygiene is essential for cure 2, 1
- Disinfection of dentures in addition to antifungal therapy is required for definitive cure 2, 1
- Remove dentures at night and clean thoroughly 1
HIV-Infected Patients
- Antiretroviral therapy should be used whenever possible to reduce recurrent infections 2, 1
- HIV patients may require more aggressive initial therapy and are at higher risk for fluconazole-resistant strains 5, 6
- For recurrent infections in HIV patients, suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 2, 7
Prevention of Recurrence
- For patients with frequent recurrences, suppressive therapy with fluconazole 100 mg three times weekly is effective 1, 7
- Daily fluconazole 100 mg has been shown to prevent thrush recurrence in immunocompromised patients 7
Important Clinical Pitfalls
- Azole-resistant infections are more common in patients with prior azole use and severely immunocompromised patients 1, 5
- Patients may relapse shortly after discontinuing therapy, especially those who are immunocompromised 4
- Fungal cultures have limited value as many individuals have asymptomatic colonization 1
- Treatment should be continued for the full recommended duration even if symptoms resolve quickly 2
- Monitor for potential drug interactions, especially with systemic azoles 1