Treatment of Oral Thrush
For oral thrush treatment, first-line therapy should be clotrimazole troches 10 mg 5 times daily for 7-14 days for mild cases, or oral fluconazole 100-200 mg daily for 7-14 days for moderate to severe cases. 1, 2
Treatment Algorithm Based on Disease Severity
Mild Oral Thrush
- Clotrimazole troches 10 mg 5 times daily for 7-14 days (first-line therapy) 1, 2
- Miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days (alternative first-line therapy) 1, 2
- Nystatin oral suspension (patients should swish and hold in mouth for as long as possible before swallowing or spitting) 1, 3
Moderate to Severe Oral Thrush
- Oral fluconazole 100-200 mg daily for 7-14 days 1, 2
- Single-dose fluconazole 150 mg has shown 96.5% efficacy in palliative care patients with advanced cancer 4
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 2
- Amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily 2, 5
Special Considerations
Denture-Related Candidiasis
- Disinfection of dentures in addition to antifungal therapy 1, 2
- Remove dentures at night and clean thoroughly 2
- Nystatin has shown efficacy in denture stomatitis when compared with photodynamic therapy 6
Immunocompromised Patients
- HIV-infected patients may require longer treatment courses or higher doses of antifungal medications 2
- Antiretroviral therapy is strongly recommended to reduce recurrent infections in HIV patients 1, 2
- Fluconazole resistance may develop with prolonged or repeated exposure, particularly in immunocompromised patients 1, 7
Recurrent Oral Thrush
- For chronic suppressive therapy, fluconazole 100 mg three times weekly is recommended 1, 2
- Always consider underlying conditions that may predispose to oral thrush, such as diabetes, immunosuppression, steroid use, or recent antibiotic therapy 1, 8
Patients Unable to Tolerate Oral Therapy
- Intravenous fluconazole 400 mg (6 mg/kg) daily 2
- Intravenous echinocandin (caspofungin, micafungin, or anidulafungin) 2
- Intravenous amphotericin B deoxycholate 0.3 mg/kg daily (less preferred option) 2
Clinical Pearls and Pitfalls
- Clotrimazole acts by altering the permeability of fungal cell membranes and is fungistatic at concentrations up to 20 mcg/mL and potentially fungicidal at higher concentrations 9
- Treatment should continue until clinical resolution of symptoms 2
- Topical amphotericin B can be effective for azole-resistant cases, though dosing regimens need further study 5
- In patients with HIV, oral thrush may indicate disease progression and low CD4 counts 1
- Recent antibiotic use may worsen oral candidiasis, requiring adjustment of antifungal therapy 5