What are the treatment options for thrush?

Treatment Options for Thrush

For oral thrush, treatment should be selected based on disease severity, with clotrimazole troches or miconazole buccal tablets for mild disease and oral fluconazole for moderate to severe disease. 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
  • 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
• 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 fluconazole, 400 mg (6 mg/kg) daily 1, 2
• Intravenous echinocandin options 1:
  • 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 (less preferred option) 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 recurrent infections 1, 2
• May require longer treatment courses or higher doses of antifungal medications 2

Recurrent Oral Thrush

• For chronic suppressive therapy: fluconazole 100 mg three times weekly 1, 2

Comparative Efficacy

• Clinical studies have shown fluconazole to be superior to nystatin for treating oral thrush in infants and immunocompromised children, with cure rates of 91-100% for fluconazole versus 32-51% for nystatin 3, 4
• Clotrimazole is effective due to its fungistatic action at concentrations up to 20 mcg/mL and potentially fungicidal activity against Candida albicans at higher concentrations 5
• Repetitive dosing of clotrimazole at three-hour intervals maintains salivary levels above the minimum inhibitory concentrations for most Candida strains 5

Treatment Pitfalls and Caveats

• Failure to address underlying predisposing factors (dentures, immunosuppression, etc.) may lead to treatment failure or recurrence 2
• For treatment-resistant thrush, especially in children, consider underlying immunodeficiency disorders 6
• When using clotrimazole troches, allow approximately 30 minutes for dissolution to achieve proper drug delivery to the oral mucosa 5
• Nystatin has higher recurrence rates and administration difficulties compared to systemic antifungals, particularly in pediatric populations 3