What is the recommended treatment for thrush?

Treatment of Thrush

For oral thrush, clotrimazole troches (10 mg 5 times daily) or fluconazole (100-200 mg daily) are the recommended first-line treatments, with selection based on severity of infection. 1

Oral Thrush Treatment Algorithm

Mild Oral Thrush

• Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1
• Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
• Nystatin suspension or pastilles four times daily 2

Moderate to Severe Oral Thrush

• Fluconazole: 100-200 mg daily for 7-14 days 1
• For palliative care patients, a single dose of fluconazole 150 mg has shown 96.5% improvement in signs and symptoms, offering reduced pill burden 3

Fluconazole-Refractory Disease

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

Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole: 400 mg (6 mg/kg) daily 1
• Intravenous echinocandin (caspofungin, micafungin, or anidulafungin) 1
• Intravenous amphotericin B deoxycholate: 0.3 mg/kg daily (less preferred due to toxicity) 1

Vaginal Thrush Treatment

Topical Treatments

• Clotrimazole cream: insert one applicatorful into the vagina at bedtime for 3 days in a row 4
• For external symptoms: apply small amount of cream to affected area twice daily for up to 7 days 4
• Other intravaginal options include:
  • Butoconazole, miconazole, terconazole creams or suppositories 2
  • Nystatin 100,000-unit vaginal tablet daily for 14 days 2

Oral Treatment

• Fluconazole 150 mg as a single oral dose is effective for uncomplicated vaginal thrush 5
• During pregnancy, topical imidazoles are preferred over nystatin 6
• Pregnancy treatment should last 7 days rather than shorter courses used in non-pregnant women 6

Special Considerations

Denture-Related Candidiasis

• Disinfect dentures in addition to antifungal therapy 1
• Remove dentures at night and clean thoroughly 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
• May require longer treatment courses or higher doses of antifungal medications 1
• Fluconazole resistance may develop, especially in patients with low CD4 counts on fluconazole prophylaxis 7

Recurrent Infections

• For recurrent oral thrush: fluconazole 100 mg three times weekly for chronic suppressive therapy 1
• For recurrent vaginal thrush: consider longer treatment duration and addressing underlying factors 8

Treatment Duration

• Continue treatment until clinical resolution of symptoms 1
• For oral thrush: typically 7-14 days 1
• For vaginal thrush: 3-7 days for most topical treatments; single dose for oral fluconazole 4, 5

Patient Preferences

• About half of patients with vaginal thrush prefer oral medication, while only 5% prefer intravaginal therapy 5
• Consider patient preference and ability to comply with treatment regimen when selecting therapy 5