What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, start with topical therapy using clotrimazole troches 10 mg five times daily for 7-14 days, and escalate to oral fluconazole 100-200 mg daily for moderate-to-severe disease or treatment failures. 1

Treatment Algorithm by Disease Severity

Mild Disease (First-Line Topical Options)

• Clotrimazole troches 10 mg five times daily for 7-14 days is the preferred topical agent 2, 1
• Miconazole mucoadhesive buccal tablet 50 mg applied to the mucosal surface over the canine fossa once daily for 7-14 days is an alternative 1
• Nystatin suspension 100,000 U/mL at 4-6 mL four times daily for 7-14 days, though generally less effective than azoles 2, 3
• Nystatin pastilles 200,000 U (1-2 pastilles) four times daily for 7-14 days 2, 3

Important administration note: When using nystatin suspension, patients should swish and hold in the mouth for as long as possible before swallowing or spitting to maximize contact time 1

Moderate to Severe Disease (Systemic Therapy Required)

• Oral fluconazole 100-200 mg (3 mg/kg) daily for 7-14 days is the treatment of choice 2, 1
• This represents a significant step up in efficacy compared to topical agents and should not be delayed in symptomatic patients 2
• Clinical response should be evident within 48-72 hours 3

Fluconazole-Refractory Disease (Second-Line Systemic Options)

When fluconazole fails after appropriate duration and dosing:

• Itraconazole solution 200 mg once daily for up to 28 days 2, 1
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 2, 1
• Voriconazole 200 mg twice daily if other agents have failed 2
• Intravenous echinocandin or amphotericin B deoxycholate 0.3 mg/kg daily for truly refractory cases 2

Special Clinical Situations

Denture-Related Candidiasis

• Always disinfect the denture in addition to antifungal therapy—treating the infection alone without addressing the denture will lead to treatment failure 2, 1, 3
• Use standard antifungal regimens as above combined with proper denture hygiene 1

Recurrent Infections Requiring Chronic Suppression

• Fluconazole 100 mg three times weekly is effective for preventing recurrences 2, 1
• However, chronic suppressive therapy is usually unnecessary and should be avoided when possible due to resistance concerns 2
• In HIV-infected patients, antiretroviral therapy (HAART) is the most important intervention to reduce recurrent infections 2, 1

HIV-Infected Patients

• Oral thrush may indicate disease progression and low CD4 counts 1
• Antiretroviral therapy should be optimized as the primary strategy to prevent recurrences 2, 1
• Symptomatic relapses occur sooner with topical therapy compared to fluconazole in this population 2

Critical Pitfalls and Caveats

Resistance development: Fluconazole resistance may develop with prolonged or repeated exposure, particularly in immunocompromised patients 1. The frequency of refractory disease is similar whether using continuous suppressive therapy or episodic treatment, though continuous therapy increases microbiological resistance 2

Underlying conditions: Always evaluate for predisposing factors including diabetes, immunosuppression, corticosteroid use, recent antibiotic therapy, or poorly controlled HIV 1. Treatment-resistant thrush in otherwise healthy individuals warrants investigation for occult immunodeficiency 4, 5

Treatment duration: If symptoms persist beyond the recommended 7-14 day treatment course, reevaluate for resistant organisms or alternative diagnoses rather than simply extending the same therapy 3

Topical vs. systemic efficacy: While topical agents work for mild disease, fluconazole and itraconazole solution are superior to ketoconazole and itraconazole capsules, and nystatin is generally less effective than fluconazole for moderate-to-severe infections 2, 3