What is the treatment for thrush (oral candidiasis) caused by vaping?

Treatment for Thrush (Oral Candidiasis) Caused by Vaping

For thrush (oral candidiasis) caused by vaping, the recommended first-line treatment is nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week. 1

Diagnosis and Etiology

• Vaping can contribute to oral candidiasis due to the thick, viscous vapor that contains sweet flavors (sucrose, sucralose, ethyl maltol) which can be retained on oral tissues and create an environment conducive to Candida growth 2
• Diagnosis should be confirmed by clinical examination showing white, thick patches on oral mucosa and tongue that can be scraped off, revealing erythematous areas underneath 1

First-Line Treatment Options

Topical Antifungal Agents:

• Nystatin oral suspension: 100,000 units (4-6 mL) four times daily for 7-14 days 1
• Miconazole oral gel: 5-10 mL held in the mouth after food four times daily for 7 days 1
• Clotrimazole troches: 10 mg troche dissolved in the mouth 5 times daily for 7-14 days 1

Oral Systemic Antifungal Agents (for moderate to severe cases):

• Fluconazole: 200 mg on first day, followed by 100 mg once daily for at least 7-14 days 1, 3
• Itraconazole solution: 200 mg daily for 7-14 days (solution preferred over capsules due to better absorption) 1

Adjunctive Measures

• Stop vaping immediately to remove the causative factor 2
• Rinse mouth with warm saline several times daily to help cleanse the oral cavity 1
• Use antiseptic oral rinses twice daily to reduce bacterial colonization:
  • 0.2% chlorhexidine digluconate mouthwash (10 mL twice daily) 1
  • 1.5% hydrogen peroxide mouthwash (10 mL twice daily) 1
• Clean and disinfect any dentures thoroughly if present 1

For Refractory Cases

• For fluconazole-resistant cases, consider itraconazole solution at higher doses (>200 mg/day) 1
• Amphotericin B oral suspension (1 mL four times daily of 100 mg/mL suspension) may be effective in patients who don't respond to azoles 1
• In severe refractory cases, intravenous amphotericin B (0.3 mg/kg/day) may be considered as a last resort 1

Follow-up and Prevention

• Evaluate response to treatment after 7-14 days 1
• If symptoms persist, consider:
  • Extending treatment duration
  • Switching to an alternative antifungal agent
  • Testing for azole resistance 4, 5
• To prevent recurrence:
  • Maintain good oral hygiene
  • Discontinue vaping permanently 2
  • Rinse mouth after using inhaled medications 1

Special Considerations

• Patients with HIV or immunocompromised status may require longer treatment courses and more aggressive management 1, 4
• For denture wearers, dentures should be removed at night and thoroughly cleaned to prevent recolonization 1
• Consider the possibility of systemic candidiasis in immunocompromised patients with persistent oral thrush despite adequate treatment 4

Common Pitfalls

• Failure to address the underlying cause (vaping) will likely result in treatment failure or recurrence 2
• Inadequate treatment duration can lead to recurrence of infection 3
• Not recognizing azole-resistant Candida strains in patients with persistent infection 4, 5
• Neglecting to consider non-albicans Candida species which may be less responsive to standard treatments 1