What are the treatment options for thrush?

Treatment of Thrush

For oral thrush, treat with fluconazole 100-200 mg daily for 7-14 days as first-line therapy for moderate to severe disease, or clotrimazole troches 10 mg five times daily for 7-14 days for mild disease. 1, 2

Oral Thrush Treatment Algorithm

Mild Disease

• Clotrimazole troches 10 mg five times daily for 7-14 days is the preferred first-line topical therapy 1, 2
• Alternative topical option: Nystatin suspension or pastilles four times daily for 7-14 days 1
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days is another first-line alternative 2

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days is the preferred systemic therapy 1, 2, 3
• Fluconazole demonstrates superior clinical cure rates and better patient compliance compared to clotrimazole troches 4
• Single-dose fluconazole 150 mg has shown 96.5% efficacy with significant symptom improvement by days 3-5 in palliative care patients 5

Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily for up to 28 days 1, 2
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1, 2
• Voriconazole 200 mg twice daily 1, 2
• Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 2

Patients Unable to Tolerate Oral Therapy

• IV fluconazole 400 mg (6 mg/kg) daily 2
• IV echinocandin (caspofungin, micafungin, or anidulafungin) 1, 2
• IV amphotericin B deoxycholate 0.3 mg/kg daily (less preferred) 1, 2

Vulvovaginal Candidiasis Treatment

Uncomplicated Disease

• Topical azole agents for 7 days OR fluconazole 150 mg single oral dose 1, 3
• Topical options include: clotrimazole 1% cream 5g intravaginally for 7-14 days, miconazole 2% cream 5g for 7 days, or terconazole 0.4% cream 5g for 7 days 1
• Imidazole drugs are significantly more effective than nystatin in pregnancy (odds ratio 0.21) 6

Complicated/Severe Disease

• Fluconazole 150 mg in two sequential doses (second dose 72 hours after initial dose) 1
• Alternative: 7-14 days of topical azole therapy 1
• Severe vulvovaginitis with extensive erythema, edema, and fissures requires longer treatment duration 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

• Initial therapy: 7-14 days of topical azole or fluconazole 150 mg repeated 3 days later to achieve mycologic remission 1
• Maintenance regimen: Fluconazole 100-150 mg once weekly for 6 months 1
• Alternative maintenance: Clotrimazole 500-mg vaginal suppository once weekly 1
• 30-40% of women will have recurrent disease once maintenance therapy is discontinued 1

Non-albicans Species (C. glabrata)

• 7-14 days of non-fluconazole azole therapy 1
• If recurrence: Boric acid 600 mg in gelatin capsule vaginally once daily for 2 weeks (70% eradication rate) 1

Special Populations

Pregnancy

• Topical imidazole therapy is preferred over nystatin 6
• Seven-day treatment courses are necessary (shorter courses used in non-pregnant women are less effective) 6
• Avoid oral fluconazole in pregnancy; use topical agents 6

HIV/AIDS Patients

• Fluconazole 100 mg daily prevents recurrent thrush with negligible toxic effects 7
• Chronic suppressive therapy with fluconazole 100 mg three times weekly for recurrent infections 2
• Antiretroviral therapy reduces incidence of recurrent infections 2

Denture-Related Candidiasis

• Disinfect dentures in addition to antifungal therapy 2
• Remove dentures at night and clean thoroughly 2

Treatment Duration and Follow-up

• Continue treatment until clinical resolution of symptoms 2
• For uncomplicated oral thrush: 7-14 days 1, 2
• For esophageal candidiasis: 14-21 days 1
• Follow-up evaluation after completing treatment is recommended to ensure complete resolution 8

Common Pitfalls to Avoid

• Inadequate treatment duration leads to recurrence - complete the full course even if symptoms improve 8
• Do not use azoles in neutropenic patients with prior azole prophylaxis 1
• Failure to address predisposing factors (inhaled steroids, diabetes, immunosuppression) results in treatment failure 9
• Laryngeal thrush is often misdiagnosed, leading to unnecessary surgical intervention - consider fluconazole trial before surgery 9
• Treatment of sex partners is not routinely recommended for vulvovaginal candidiasis unless male partner has symptomatic balanitis 1