What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, start with clotrimazole troches 10 mg dissolved slowly in the mouth 5 times daily for 7-14 days; for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Disease (First-Line Options)

• Clotrimazole troches 10 mg dissolved slowly 5 times daily for 7-14 days is the preferred topical therapy 1, 2
• Miconazole mucoadhesive buccal tablet 50 mg applied once daily to the mucosal surface over the canine fossa for 7-14 days is an equally effective alternative 1, 2
• Nystatin suspension (100,000 U/mL) 4-6 mL swished and swallowed 4 times daily for 7-14 days, or nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily are less preferred alternatives 1

Key point: Clotrimazole maintains salivary concentrations sufficient to inhibit Candida for up to 3 hours after the troche dissolves over approximately 30 minutes, with drug binding to oral mucosa providing sustained release 3

Moderate to Severe Disease

• Oral fluconazole 100-200 mg once daily for 7-14 days is the recommended systemic therapy 1, 2
• This represents a significant advantage over topical agents, with superior clinical cure rates and better patient compliance due to once-daily dosing 4
• Single-dose fluconazole 150 mg has shown 96.5% improvement in signs and symptoms in palliative care patients, though this is not the standard guideline recommendation 5

Special Clinical Situations

Denture-Related Candidiasis

• Disinfect dentures in addition to antifungal therapy - this is essential for treatment success 1, 2
• Remove dentures at night and clean thoroughly 2
• Antifungal therapy alone without denture disinfection leads to treatment failure 1

HIV-Infected Patients

• Initiate or optimize antiretroviral therapy - this is the most important intervention to reduce recurrent infections 1, 2
• May require longer treatment courses or higher doses of antifungal medications 2
• Effective antiretroviral therapy has dramatically reduced the prevalence of both oropharyngeal and esophageal candidiasis 1

Recurrent Oral Thrush

• Chronic suppressive therapy with fluconazole 100 mg three times weekly is recommended for patients with frequent recurrences 1, 2
• Prophylaxis with fluconazole 100 mg daily has been shown to prevent thrush episodes entirely in high-risk patients, though this is typically reserved for those with multiple recurrences 6

Fluconazole-Refractory Disease

When patients fail to respond to fluconazole after 7-14 days:

• Itraconazole solution 200 mg once daily for up to 28 days is the first alternative 1, 2
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days is equally effective 1, 2
• Voriconazole 200 mg twice daily is another option 1, 2
• Amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily can be used for resistant cases 1, 2

Important caveat: True azole resistance in immunocompetent patients is extremely rare; consider non-adherence, inadequate dosing, or alternative diagnoses before escalating therapy 1

Patients Unable to Tolerate Oral Therapy

For patients who cannot swallow or tolerate oral medications:

• Intravenous fluconazole 400 mg (6 mg/kg) daily is the preferred parenteral option 1, 2
• Intravenous echinocandins are alternatives: caspofungin (70 mg loading dose, then 50 mg daily), micafungin (100 mg daily), or anidulafungin (200 mg loading dose, then 100 mg daily) 1, 2
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily is a less preferred alternative due to toxicity 1, 2
• De-escalate to oral fluconazole 200-400 mg daily once the patient can tolerate oral intake 1

Common Pitfalls to Avoid

• Do not use topical therapy for moderate-severe disease - systemic absorption is necessary for adequate treatment 1
• Ensure adequate contact time with topical agents - troches must dissolve slowly over 15-30 minutes, not be chewed or swallowed 3
• Address underlying risk factors - uncontrolled diabetes, inhaled corticosteroid use without mouth rinsing, smoking, and immunosuppression must be managed 1
• Consider esophageal involvement if symptoms persist despite appropriate oral therapy - dysphagia or odynophagia suggests esophageal candidiasis requiring higher fluconazole doses (200-400 mg daily) for 14-21 days 1