Treatment of Oral Thrush
For mild oral thrush, clotrimazole troches (10 mg 5 times daily) or miconazole mucoadhesive buccal tablets (50 mg once daily) for 7-14 days are the recommended first-line treatments. 1, 2
Treatment Algorithm Based on Disease Severity
Mild Disease
- Clotrimazole troches, 10 mg 5 times daily for 7-14 days 1, 2, 3
- Alternative: Miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1, 2
- Alternative: 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 1, 4
Moderate to Severe Disease
- Oral fluconazole, 100-200 mg daily, for 7-14 days 1, 2
- Treatment should continue until clinical resolution of symptoms 2
Fluconazole-Refractory Disease
- Itraconazole solution, 200 mg once daily for up to 28 days 1, 2
- Posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days 1, 2
- Voriconazole, 200 mg twice daily 1, 2
- Amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily 1, 2
For Patients Unable to Tolerate Oral Therapy
- 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, 2
- Intravenous amphotericin B deoxycholate, 0.3 mg/kg daily 1, 2
Special Considerations
Denture-Related Candidiasis
- Disinfection of the denture in addition to antifungal therapy is essential 1, 2
- Remove dentures at night and clean thoroughly 2
HIV-Infected Patients
- Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1, 2
- May require longer treatment courses or higher doses of antifungal medications 2
- Fluconazole has shown superior efficacy compared to clotrimazole in HIV patients 5
Recurrent Oral Thrush
- For patients with recurrent infection, fluconazole 100 mg three times weekly is recommended for chronic suppressive therapy 1, 2
- Prophylactic fluconazole (100 mg daily) has been shown to effectively prevent recurrent thrush in immunocompromised patients 6
Pediatric Considerations
- In infants, fluconazole suspension 3 mg/kg in a single daily dose for 7 days has shown superior efficacy (100% cure rate) compared to nystatin oral suspension (32% cure rate) 7
- Treatment-resistant thrush in children may require further investigation for underlying conditions 8
Palliative Care Patients
- Single-dose fluconazole 150 mg has shown 96.5% improvement in signs and symptoms in palliative care and hospice patients with oral thrush 9
- This approach reduces pill burden in patients with advanced cancer 9
Treatment Efficacy and Compliance
- Fluconazole tablets show superior patient compliance compared to clotrimazole troches due to once-daily dosing versus five times daily dosing 5
- Clotrimazole's action is fungistatic at concentrations up to 20 mcg/mL and may be fungicidal against Candida albicans at higher concentrations 3
- After oral administration of a 10 mg clotrimazole troche, inhibitory concentrations persist in saliva for up to three hours 3