What is the treatment for painful white spots on the tongue?

Treatment for Painful White Spots on the Tongue

For painful white spots on the tongue, oral fluconazole 200-400 mg daily for 7-14 days is the most effective treatment, as these lesions are typically caused by oral thrush (oropharyngeal candidiasis). 1, 2

Diagnosis and Clinical Presentation

• Painful white spots on the tongue typically represent oral thrush (oropharyngeal candidiasis), characterized by white plaque-like lesions that may bleed when scraped 2
• Diagnosis is primarily clinical based on the characteristic appearance of lesions 2
• Common symptoms include pain, burning sensation, and altered taste sensation 2

First-Line Treatment Options

Systemic Therapy

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 7-14 days is the recommended first-line treatment 1
• For the first day, a loading dose of twice the daily dose (400 mg) is recommended to achieve steady-state plasma concentrations more quickly 3
• Clinical resolution typically occurs within several days, but treatment should continue for at least 2 weeks to prevent relapse 3

Topical Therapy (for mild cases)

• Clotrimazole troches (10 mg, 5 times daily for 7-14 days) 1
• Nystatin suspension (100,000 U/mL, 4-6 mL four times daily) or pastilles (200,000 U, 1-2 pastilles 4-5 times daily for 7-14 days) 1
• Miconazole 50 mg mucoadhesive buccal tablets once daily 1

Treatment Algorithm

1. For mild cases or patients who cannot tolerate systemic therapy:

   • Begin with topical agents (clotrimazole troches or nystatin) 1
   • Continue for 7-14 days 1

2. For moderate to severe cases:

   • Oral fluconazole 200-400 mg daily for 7-14 days 1, 2
   • Loading dose of 400 mg on first day, followed by 200 mg daily 3

3. For patients who cannot tolerate oral therapy:

   • Intravenous fluconazole 400 mg daily 1
   • Or echinocandins (micafungin, caspofungin, or anidulafungin) 1

4. For fluconazole-refractory cases:

   • Itraconazole solution 200 mg daily (64-80% response rate) 1, 4
   • Posaconazole suspension (75% response rate) 1
   • Voriconazole 200 mg twice daily 1

Special Considerations

• For denture-related candidiasis, disinfection of dentures in addition to antifungal therapy is essential 1, 2
• In HIV-infected patients, antiretroviral therapy should be used alongside antifungal treatment to reduce recurrence 1, 5
• For recurrent infections, fluconazole 100 mg three times weekly can be used as suppressive therapy 1, 2

Monitoring and Follow-up

• Clinical improvement should be seen within 48-72 hours of initiating therapy 1
• Mycological cure typically occurs 4-7 days after starting treatment 1
• If no improvement after 7 days, consider:
  • Alternative diagnosis
  • Fluconazole-resistant Candida species
  • Need for higher dosage or alternative antifungal agent 1

Common Pitfalls

• Failure to identify and address underlying predisposing factors (immunosuppression, steroid use, diabetes) 5, 2
• Inadequate duration of therapy leading to recurrence 3
• Not considering fluconazole resistance in patients with previous azole exposure 1, 5
• Overlooking potential esophageal involvement in patients with dysphagia 2