What are the treatment options for chronic oral thrush?

Treatment Options for Chronic Oral Thrush

For chronic oral thrush, fluconazole 100 mg three times weekly is recommended as the most effective chronic suppressive therapy when recurrent infections cannot be controlled with shorter courses of treatment. 1, 2

First-Line Treatment Based on Disease Severity

Mild Disease

• 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
• 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

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

Management of Fluconazole-Refractory Disease

For patients who don't respond to fluconazole, the following options are recommended:

• Itraconazole solution, 200 mg once daily for up to 28 days 1, 2
  • Clinical studies show response rates of approximately 55% in HIV-positive patients who were clinically unresponsive to fluconazole 3
• 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

Intravenous Options for Severe or Refractory Cases

For patients unable to tolerate oral therapy or with severe refractory disease:

• Intravenous echinocandin (options include):
  • Caspofungin: 70-mg loading dose, then 50 mg daily 1
  • Micafungin: 100 mg daily 1
  • Anidulafungin: 200-mg loading dose, then 100 mg daily 1
• Intravenous amphotericin B deoxycholate, 0.3 mg/kg daily (less preferred alternative) 1

Chronic Suppressive Therapy for Recurrent Infections

• For patients with recurrent oral thrush, fluconazole 100 mg three times weekly is recommended 1, 2
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 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
• Apply topical antifungals to the denture-bearing areas 1

Underlying Conditions

• Identify and address predisposing factors such as:
  • Immunodeficiency disorders (including HIV) 4, 5
  • Diabetes mellitus 6
  • Prolonged use of antibiotics or immunosuppressive drugs 6
  • Hyposalivation 6

Monitoring for Resistance

• Consider antifungal susceptibility testing in cases of persistent or recurrent thrush despite appropriate therapy 5
• Be aware that resistance to fluconazole can develop, particularly in immunocompromised patients with prolonged exposure 5

Prevention of Recurrence

• For patients with oral thrush following nebulizer therapy, rinse the mouth out after nebulizing medications, especially steroids and antibiotics 1
• For patients with Stevens-Johnson syndrome/toxic epidermal necrolysis with oral involvement, apply white soft paraffin ointment to the lips every 2 hours and use mucoprotectant mouthwash three times daily to prevent candidal infection 1