What is the standard treatment for oral candidiasis (thrush)?

Standard Treatment for Oral Thrush (Candidiasis)

For mild oral thrush, first-line treatment is clotrimazole troches 10 mg 5 times daily or miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days. For moderate to severe disease, oral fluconazole 100-200 mg daily for 7-14 days is recommended. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• Clotrimazole troches 10 mg 5 times daily for 7-14 days (strong recommendation; high-quality evidence) 1
• Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days (strong recommendation; high-quality evidence) 1
• Alternative options include 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 (strong recommendation; moderate-quality evidence) 1

Moderate to Severe Oral Thrush

• Oral fluconazole 100-200 mg daily for 7-14 days (strong recommendation; high-quality evidence) 1
• Fluconazole has demonstrated superior mycological cure rates compared to topical agents 2, 3

Treatment for Refractory Cases

For fluconazole-refractory disease, consider:

• Itraconazole solution 200 mg once daily for up to 28 days (strong recommendation; moderate-quality evidence) 1, 4
• Posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily for up to 28 days (strong recommendation; moderate-quality evidence) 1
• Voriconazole 200 mg twice daily (strong recommendation; moderate-quality evidence) 1
• Amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily (strong recommendation; moderate-quality evidence) 1
• For severely refractory cases: intravenous echinocandin or intravenous amphotericin B deoxycholate 0.3 mg/kg daily (weak recommendation; moderate-quality evidence) 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of the denture is essential in addition to antifungal therapy (strong recommendation; moderate-quality evidence) 1
• Remove dentures at night and clean thoroughly 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections (strong recommendation; high-quality evidence) 1
• For recurrent infections in HIV patients, suppressive therapy with fluconazole 100 mg three times weekly may be necessary (strong recommendation; high-quality evidence) 1

Pediatric Patients

• Fluconazole suspension has shown superior efficacy compared to nystatin suspension in infants (100% vs 32% clinical cure rates) 5
• For children, dosing should be adjusted based on weight 1

Monitoring and Follow-up

• Clinical response to topical therapy should be seen within 48-72 hours 1
• For moderate to severe cases treated with fluconazole, improvement typically occurs within 5-7 days 1
• Chronic suppressive therapy is usually unnecessary unless the patient has frequent recurrences 1

Common Pitfalls and Caveats

• Topical agents (nystatin, clotrimazole) require multiple daily applications, which may reduce compliance compared to once-daily fluconazole 2, 6
• Itraconazole solution and capsules are not interchangeable; only the solution has been proven effective for oral candidiasis 4
• For denture-related candidiasis, failure to address denture hygiene will lead to treatment failure 1
• Long-term azole use may lead to development of resistant Candida strains, particularly in immunocompromised patients 3
• Oral cultures are generally not needed for diagnosis or management of uncomplicated cases 1

By following this evidence-based approach to treating oral thrush based on disease severity, most patients will experience resolution of symptoms with appropriate therapy.