What is the treatment for oral thrush?

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 recommended as first-line therapy, while moderate to severe cases should be treated with oral fluconazole (100-200 mg daily) for 7-14 days. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• First-line options:
  • Clotrimazole troches, 10 mg 5 times daily for 7-14 days 1, 2
  • Miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1, 2
• Alternative options:
  • Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days 1, 3
  • Nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily for 7-14 days 1

Moderate to Severe Oral Thrush

• Oral fluconazole, 100-200 mg daily for 7-14 days 1, 2
• Single-dose fluconazole 150 mg has shown efficacy in palliative care patients with oral thrush, with 96.5% showing >50% improvement in signs and symptoms 4

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

Patients Unable to Tolerate Oral Therapy

• Intravenous echinocandin options 1, 2:
  • Caspofungin: 70-mg loading dose, then 50 mg daily
  • Micafungin: 100 mg daily
  • Anidulafungin: 200-mg loading dose, then 100 mg daily
• 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
• Dentures should be removed at night and cleaned 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 superiority over clotrimazole in HIV patients with better compliance due to once-daily dosing 5

Recurrent Oral Thrush

• For patients with recurrent infections, fluconazole 100 mg three times weekly is recommended for chronic suppressive therapy 1, 2
• Daily fluconazole (100 mg) has been shown to effectively prevent recurrent thrush in immunocompromised patients 6

Clinical Pearls and Pitfalls

• Fluconazole has demonstrated superior clinical cure rates compared to nystatin suspension in infants (100% vs 32%) 7
• Persistent or recurrent thrush despite appropriate therapy may indicate underlying immunodeficiency or resistance and warrants further investigation 8
• Clotrimazole acts by altering the permeability of fungal cell membranes and maintains therapeutic salivary levels for up to three hours after dissolution 9
• Treatment should be continued until clinical resolution of symptoms 2
• Azole-resistant C. albicans infections are extremely rare but can occur following prolonged azole exposure 1