What is the recommended treatment for oral candidiasis?

Treatment of Oral Candidiasis

For oral candidiasis, treatment should be based on disease severity, with fluconazole 100-200 mg daily for 7-14 days recommended for moderate to severe disease, and topical agents like clotrimazole troches for mild cases. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Oral Candidiasis

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

Moderate to Severe Oral Candidiasis

• Oral fluconazole, 100-200 mg (3 mg/kg) daily for 7-14 days 3, 1, 2
• Treatment should continue until clinical resolution of symptoms 2

Fluconazole-Refractory Disease

• Itraconazole solution, 200 mg daily for up to 28 days 3, 1, 2, 5
• Posaconazole suspension, 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 3, 1, 2
• Voriconazole, 200 mg twice daily 3, 2
• Amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily 3, 2

For Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole, 400 mg (6 mg/kg) daily 3, 2
• Intravenous echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100-150 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) 3, 1, 2
• Intravenous amphotericin B deoxycholate, 0.3-0.7 mg/kg daily 3, 2

Special Considerations

Denture-Related Candidiasis

• Disinfection of dentures is essential in addition to antifungal therapy 3, 1, 2
• Dentures should be removed at night and cleaned thoroughly 2
• Topical antifungals may be applied directly to the denture-bearing areas 6

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 3, 1, 2
• May require longer treatment courses or higher doses of antifungal medications 2, 7
• For recurrent infections, chronic suppressive therapy with fluconazole 100 mg three times weekly is recommended 3, 1, 2

Recurrent Oral Candidiasis

• Identify and address underlying risk factors (e.g., immunosuppression, xerostomia, antibiotic use) 6, 8
• For chronic suppressive therapy, fluconazole 100-200 mg three times weekly is recommended 3, 2

Common Pitfalls to Avoid

• Inadequate duration of therapy leading to recurrence 1
• Discontinuing therapy prematurely once symptoms resolve rather than completing the full course 1
• Failing to address underlying risk factors such as immunosuppression, xerostomia, or denture hygiene 6, 8
• Relying solely on cultures from respiratory secretions for diagnosis, as these have poor predictive value 3, 1
• Not considering drug interactions when prescribing systemic azoles, particularly in patients on multiple medications 8

Comparative Efficacy of Treatment Options

• Systemic antifungals (fluconazole, itraconazole) generally provide faster clinical response compared to topical agents 9
• Itraconazole solution has shown impressive clinical and mycological response rates within 1 week of treatment in some studies 9
• Topical agents may have higher relapse rates compared to systemic therapy 9, 7
• Resistance to fluconazole may develop, particularly in immunocompromised patients with recurrent infections 7