What is the recommended treatment for oral thrush in adults?

Treatment of Oral Thrush in Adults

Initial Treatment Based on Disease Severity

For mild oral thrush, start with topical therapy using clotrimazole troches 10 mg five times daily for 7-14 days, while moderate to severe disease requires oral fluconazole 100-200 mg daily for 7-14 days. 1, 2

Mild Disease - Topical Options

• Clotrimazole troches 10 mg dissolved slowly in the mouth 5 times daily for 7-14 days is the preferred first-line topical agent 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 that offers superior convenience with once-daily dosing 1, 2
• Nystatin suspension 100,000 U/mL administered as 4-6 mL four times daily for 7-14 days is an alternative topical option, though generally less preferred 1, 3
• Nystatin pastilles 200,000 U each, using 1-2 pastilles four times daily for 7-14 days, can also be used 1

Moderate to Severe Disease - Systemic Therapy

• Oral fluconazole 100-200 mg once daily for 7-14 days is the treatment of choice for moderate to severe oral thrush, offering superior efficacy and convenience compared to topical agents 1, 2
• Fluconazole demonstrates better patient compliance due to once-daily dosing compared to topical agents requiring multiple daily applications 4
• Treatment should be continued until clinical resolution of symptoms, typically 7-14 days 1, 2

Fluconazole-Refractory Disease

When patients fail to respond to fluconazole therapy after 7-14 days, escalate to alternative systemic antifungals:

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

Parenteral Options for Severe Refractory Disease

• Intravenous echinocandins (caspofungin 70 mg loading dose then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading dose then 100 mg daily) are reserved for severe refractory cases 1
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily is a less preferred alternative 1

Special Clinical Situations

Denture-Related Candidiasis

• Disinfection of dentures is mandatory in addition to antifungal therapy for successful treatment 1, 2
• Patients should remove dentures at night and clean them thoroughly 2
• Without proper denture hygiene, antifungal therapy alone will result in treatment failure and rapid relapse 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent oral thrush and should be optimized alongside antifungal treatment 1, 2
• HIV-infected patients may require longer treatment courses or higher doses of antifungal medications 2
• Routine primary prophylaxis with fluconazole is not recommended despite its ability to reduce mucosal candidiasis risk, due to concerns about drug resistance, drug interactions, cost, and the low mortality associated with oral thrush 1

Recurrent Oral Thrush

• For patients with recurrent infections, chronic suppressive therapy with fluconazole 100 mg three times weekly is recommended after successful treatment of the acute episode 1, 2
• Chronic suppressive therapy is usually unnecessary for most patients and should be reserved for those with documented recurrent infections 1

Patients Unable to Tolerate Oral Therapy

For hospitalized or severely ill patients who cannot take oral medications:

• Intravenous fluconazole 400 mg (6 mg/kg) daily is the preferred parenteral option 1, 2
• Intravenous echinocandins (caspofungin, micafungin, or anidulafungin) are effective alternatives 1, 2
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily is a less preferred alternative due to toxicity concerns 1, 2

Common Pitfalls to Avoid

• Do not use ketoconazole or itraconazole capsules as they have variable absorption and are less effective than fluconazole or itraconazole solution 1
• Avoid prescribing topical therapy for moderate to severe disease, as systemic therapy is required for adequate treatment 1, 2
• Do not discontinue therapy prematurely; continue treatment for at least 48 hours after symptoms resolve and until clinical resolution is confirmed 1, 3
• Single-dose fluconazole 150 mg, while studied in palliative care patients with 96.5% improvement rates, is not included in standard guidelines and should not replace the recommended 7-14 day courses 5