What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, start with topical clotrimazole troches 10 mg 5 times daily for 7-14 days; for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1, 2

Treatment Algorithm by Disease Severity

Mild Oral Thrush (First-Line Topical Therapy)

• Clotrimazole troches 10 mg dissolved slowly in the mouth 5 times daily for 7-14 days is the preferred first-line treatment 1, 2
• Miconazole mucoadhesive buccal 50 mg tablet applied once daily to the mucosal surface over the canine fossa for 7-14 days is an equally effective alternative 1, 2
• Nystatin oral suspension (swish and hold in mouth as long as possible before swallowing) remains an option, though it is associated with higher recurrence rates and more difficult administration 3, 4, 5

The IDSA guidelines provide strong recommendations with high-quality evidence for both clotrimazole and miconazole as first-line agents 1, 2. While nystatin is FDA-approved for oral candidiasis 4, research demonstrates fluconazole's superiority over nystatin, with cure rates of 100% versus 32% in infants 5.

Moderate to Severe Oral Thrush (Systemic Therapy)

• Oral fluconazole 100-200 mg daily for 7-14 days is the treatment of choice 1, 2
• Continue treatment until complete clinical resolution of symptoms 2
• A single 150 mg dose of fluconazole has shown 96.5% efficacy in palliative care patients, though this is not standard guideline-based dosing 6

Fluconazole is superior to ketoconazole and has become the systemic drug of choice due to excellent antifungal properties, high patient acceptance, and proven efficacy 3, 7.

Refractory and Resistant Disease

Fluconazole-Refractory Oral Thrush

When fluconazole fails after appropriate treatment duration:

• Itraconazole solution 200 mg once daily for up to 28 days (better absorbed than capsules) 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 2
• Amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily 2

The IDSA provides strong recommendations with moderate-quality evidence for itraconazole and posaconazole in this setting 1. Resistance typically develops with prolonged or repeated fluconazole exposure, particularly in immunocompromised patients 1.

Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole 400 mg (6 mg/kg) daily 2
• Intravenous echinocandins (caspofungin, micafungin, or anidulafungin) 3, 2
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily (less preferred due to toxicity) 3, 2

Special Clinical Situations

Denture-Related Candidiasis

• Always disinfect dentures in addition to antifungal therapy 1, 2
• Remove dentures at night and clean thoroughly 2
• Failure to address the denture as a reservoir will result in treatment failure 1

Recurrent Infections Requiring Chronic Suppression

• Fluconazole 100 mg three times weekly for long-term suppressive therapy 1, 2
• This regimen is effective in preventing recurrences in patients with AIDS and cancer 3

HIV-Infected Patients

• Initiate or optimize antiretroviral therapy to reduce recurrence incidence 1, 2
• Oral thrush may indicate disease progression and low CD4 counts 1
• These patients may require longer treatment courses or higher antifungal doses 2
• Symptomatic relapses occur sooner with topical therapy compared to fluconazole 3

Critical Clinical Pearls

• Always investigate underlying predisposing conditions: diabetes, immunosuppression, corticosteroid use, recent antibiotic therapy, or inhaled corticosteroids 1
• Topical therapy relies on prolonged mucosal contact—clotrimazole troches should dissolve slowly over 30 minutes to maintain adequate salivary concentrations 8
• Itraconazole solution has superior absorption compared to capsules due to topical mucosal effects in addition to systemic absorption 3
• Fluconazole resistance can develop with repeated exposure, requiring escalation to alternative azoles or amphotericin B 1
• For esophageal extension of candidiasis, topical therapy is completely ineffective and systemic treatment is mandatory 3