What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, start with clotrimazole troches 10 mg five 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 Based on Disease Severity

Mild Disease

• Clotrimazole troches 10 mg administered five times daily for 7-14 days is the preferred topical option 1, 2
• Alternative topical options include:
  • Nystatin suspension 100,000 U/mL at 4-6 mL four times daily for 7-14 days (patients should swish and hold in mouth as long as possible before swallowing) 1, 3
  • Nystatin pastilles 200,000 U administered 1-2 pastilles four times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 2

Moderate to Severe Disease

• Oral fluconazole 100-200 mg (3 mg/kg) daily for 7-14 days is the treatment of choice 1, 2
• Fluconazole demonstrates superior efficacy compared to topical agents, with lower relapse rates in immunocompromised patients 1
• This systemic approach is particularly important when patients have difficulty with topical medication adherence or have extensive disease 1

Fluconazole-Refractory Disease

When fluconazole fails after appropriate duration and dosing:

• First-line alternatives: Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1, 2
• Second-line alternatives when other agents fail:
  • Voriconazole 200 mg twice daily 1
  • Amphotericin B deoxycholate oral suspension 100 mg/mL, 1 mL four times daily 1
  • Intravenous echinocandin or amphotericin B deoxycholate 0.3 mg/kg daily for truly refractory cases 1

Special Clinical Scenarios

Denture-Related Candidiasis

• Always combine antifungal therapy with denture disinfection—treating the infection alone without addressing the denture reservoir will result in treatment failure 1, 2

Recurrent Infections Requiring Chronic Suppression

• Fluconazole 100 mg three times weekly is effective for chronic suppressive therapy 1, 2
• However, chronic suppressive therapy is usually unnecessary for HIV-infected patients on effective antiretroviral therapy 1
• For HIV-infected patients, initiation or optimization of HAART is the most important intervention to reduce recurrent infections 1, 2

Critical Clinical Pitfalls

Resistance Development

• Fluconazole resistance may develop with prolonged or repeated exposure, particularly in immunocompromised patients 2
• Consider C. glabrata or C. krusei in refractory cases, as these species demonstrate intrinsic or acquired fluconazole resistance 1

Underlying Predisposing Conditions

• Always evaluate for diabetes, immunosuppression (including HIV), corticosteroid use, recent broad-spectrum antibiotic therapy, or xerostomia 2
• In HIV-infected patients, oral thrush may indicate disease progression and low CD4 counts, warranting assessment of antiretroviral therapy status 2

Topical Therapy Considerations

• Topical agents require adequate contact time with oral mucosa—nystatin suspension must be swished and held in the mouth as long as possible before swallowing 2
• Clotrimazole troches must dissolve slowly in the mouth (approximately 30 minutes) to maintain adequate salivary concentrations 4
• Topical therapy alone may result in higher symptomatic relapse rates compared to systemic fluconazole, particularly in immunocompromised patients 1

Alternative Single-Dose Approach for Palliative Care

• In hospice or palliative care patients with advanced cancer who have high pill burden, a single dose of fluconazole 150 mg achieved >50% improvement in 96.5% of patients by days 3-5 5
• This approach reduces pill burden while maintaining efficacy in this specific population 5