Treatment of Oral Candidiasis
For mild oral candidiasis, start with topical clotrimazole troches 10 mg five times daily or miconazole mucoadhesive buccal 50-mg tablet once daily for 7-14 days; for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1
Initial Treatment Selection
Mild disease (uncomplicated, immunocompetent patients):
- Clotrimazole troches 10 mg five times daily for 7-14 days 2, 1
- Alternative: Nystatin suspension 100,000 U/mL, 4-6 mL four times daily, or nystatin pastilles 200,000 U, 1-2 pastilles 4-5 times daily for 7-14 days 2, 1
- Alternative: Miconazole mucoadhesive buccal 50-mg tablet applied once daily 1
Moderate to severe disease or immunocompromised patients:
- Oral fluconazole 100-200 mg daily for 7-14 days is superior to topical therapy and provides more durable responses with better prevention of recurrence 2, 1, 3
- Fluconazole is particularly preferred in HIV-infected patients because symptomatic relapses occur sooner with topical therapy 2, 3
- Clinical response typically occurs within 5-7 days with fluconazole 1
Fluconazole-Refractory Disease
When oral candidiasis fails to respond to fluconazole, escalate therapy systematically:
- First-line for refractory disease: Itraconazole solution 200 mg once daily (or up to 200 mg twice daily for fluconazole-unresponsive cases) for up to 28 days—effective in approximately two-thirds of fluconazole-refractory cases 2, 1, 4
- Second-line options: Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
- Alternative: Voriconazole 200 mg twice daily 1
- Topical salvage: Amphotericin B oral suspension 100 mg/mL four times daily 2, 1
- Last resort: Intravenous amphotericin B 0.3 mg/kg/day for patients with refractory disease who fail all oral options 2
Critical Pitfalls to Avoid
Do not use topical therapy for esophageal candidiasis—it is completely ineffective because topical agents cannot reach the esophageal mucosa in therapeutic concentrations. 3 Esophageal candidiasis always requires systemic therapy with fluconazole 200-400 mg daily for 14-21 days. 3
Do not assume topical agents are "safer" to avoid resistance—resistance develops with both topical and systemic therapy at similar rates. 2, 3 The choice should be based on disease severity and patient factors, not resistance concerns alone. 3
Do not use itraconazole capsules interchangeably with itraconazole solution—the solution is better absorbed and more effective; only the solution formulation has demonstrated efficacy for oral candidiasis. 2, 4
Special Considerations
Denture-related candidiasis:
- Disinfection of the denture is essential in addition to antifungal therapy 1
- Use 2% chlorhexidine gluconate solution or equal parts hydrogen peroxide and water to disinfect dentures and oral hygiene aids 5
- Discard or disinfect toothbrushes and denture brushes, as they may serve as sources of reinfection 5
HIV-infected patients:
- Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
- For frequent recurrences, suppressive therapy with fluconazole 100 mg three times weekly may be necessary 1
- Continuous suppressive therapy increases the rate of isolates with elevated fluconazole MICs but does not increase the frequency of clinically refractory disease 2
Recurrent infections:
- Suppressive therapy is effective for preventing recurrent infections but should be reserved for frequent or disabling recurrences to reduce the likelihood of antifungal resistance development 2
- Use of HAART in HIV patients has been associated with declining rates of C. albicans carriage and reduced frequency of symptomatic episodes 2
Monitoring
- Clinical response to topical therapy should be seen within 48-72 hours 1
- Oropharyngeal fungal cultures are of little benefit because many individuals have asymptomatic colonization and treatment frequently does not result in microbiological cure 2, 1
- For fluconazole-refractory disease treated with itraconazole, clinical response will be seen in 2-4 weeks 4