What is the treatment for oral thrush in adults?

Treatment of Oral Thrush in Adults

Oral fluconazole 100-200 mg daily for 7-14 days is the preferred first-line treatment for oral thrush in adults due to superior efficacy, convenience, and tolerability compared to topical agents. 1

First-Line Treatment Options

Systemic Therapy (Preferred)

• Fluconazole 100-200 mg orally once daily for 7-14 days is the drug of choice, demonstrating superior efficacy to topical agents in controlled trials 1
• Response is typically rapid, with improvement in signs and symptoms within 48-72 hours 1
• Alternative systemic agents include:
  • Itraconazole oral solution 200 mg daily for 7-14 days (as effective as fluconazole but less well tolerated) 1
  • Posaconazole oral solution 400 mg once daily (as effective as fluconazole, generally better tolerated than itraconazole, and superior at sustaining clinical success after therapy discontinuation) 1

Topical Therapy (Alternative for Mild Cases)

Initial episodes can be treated with topical agents, though they are less convenient: 1

• Clotrimazole troches 10 mg dissolved slowly in mouth 5 times daily 1
• Nystatin suspension or pastilles 4 times daily 1
• Miconazole mucoadhesive tablets once daily 1

Important caveat: Ketoconazole and itraconazole capsules should not be used due to variable absorption and inferior efficacy 1

Treatment Duration and Monitoring

• Standard treatment duration is 7-14 days for uncomplicated oropharyngeal candidiasis 1
• Most patients show improvement within 48-72 hours of initiating therapy 1
• If prolonged azole therapy exceeds 21 days, periodic monitoring of liver chemistry studies should be considered 1

Management of Refractory Disease

Treatment failure is defined as persistent signs and symptoms after 7-14 days of appropriate therapy 1

For fluconazole-refractory oral thrush (occurring in approximately 4-5% of immunocompromised patients): 1

1. Second-line: Itraconazole oral solution (effective in approximately two-thirds of fluconazole-refractory cases) 1
2. Third-line: Posaconazole immediate-release oral suspension 400 mg twice daily for 28 days (effective in 75% of azole-refractory cases) 1
3. Fourth-line: IV amphotericin B (conventional, lipid complex, or liposomal formulations) for severe refractory disease 1
4. Alternative: Voriconazole 200 mg twice daily 1

Special Populations and Considerations

HIV-Infected Patients

• Antiretroviral therapy (ART) reduces the frequency of mucosal candidiasis and should be optimized 1
• Refractory cases typically resolve when immunity improves with ART 1
• Routine primary or secondary prophylaxis is not recommended due to low mortality, effectiveness of acute therapy, risk of resistance development, drug interactions, and cost 1

Pregnancy

• Fluconazole should be used with caution; teratogenic effects have been reported with prolonged high-dose use in the first trimester, though single-dose treatment has not shown increased anomalies 1
• Topical azoles are preferred during pregnancy when possible 1

Patients with Hematological Malignancies

• Oral azoles (fluconazole) are recommended for rapid response 1
• Topical polyenes are recommended for mild forms 1
• Azole-resistant Candida species can be selected even without prolonged treatment, requiring species identification and susceptibility testing 1

Common Pitfalls to Avoid

• Do not use topical therapy alone for severe or esophageal involvement (systemic therapy is required) 1
• Avoid prolonged azole use without monitoring for liver toxicity if treatment exceeds 21 days 1
• Do not ignore treatment failure beyond 7-14 days; switch to alternative agents rather than continuing ineffective therapy 1
• Be aware of azole resistance development, particularly in immunocompromised patients with CD4+ counts <50 cells/µL who have received multiple azole courses 1
• Consider underlying systemic disease if thrush is persistent without obvious immunocompromise 2

Adverse Effects

• Short courses of topical therapy rarely cause adverse effects, though cutaneous hypersensitivity reactions (rash, pruritus) may occur 1
• Oral azoles can cause nausea, vomiting, diarrhea, abdominal pain, or transaminase elevations 1
• Echinocandins (if used for refractory cases) are generally safe with minimal side effects 1