Treatment of Oral Thrush (Oropharyngeal Candidiasis)
For mild oral thrush, start with clotrimazole troches 10 mg five times daily for 7-14 days, and for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1
First-Line Treatment by Disease Severity
Mild Disease
- Clotrimazole troches 10 mg five times daily for 7-14 days is the preferred topical option 1, 2
- Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days is an equally effective alternative 1
- Nystatin suspension (100,000 U/mL) 4-6 mL four times daily OR nystatin pastilles (200,000 U each) 1-2 pastilles four times daily for 7-14 days are additional alternatives 1, 2
Moderate to Severe Disease
- Oral fluconazole 100-200 mg daily for 7-14 days is the treatment of choice 1, 2
- This systemic approach is more effective than topical agents for extensive disease 1
- Fluconazole offers superior compliance compared to multiple-daily-dose topical regimens 3
Refractory or Fluconazole-Resistant Disease
When patients fail initial fluconazole therapy or have known azole-resistant organisms:
- 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
- Voriconazole 200 mg twice daily is an alternative 1
- Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily for azole-refractory cases 1, 4
- Intravenous echinocandin (caspofungin 70-mg loading dose, then 50 mg daily; micafungin 100 mg daily; or anidulafungin 200-mg loading dose, then 100 mg daily) OR intravenous amphotericin B deoxycholate 0.3 mg/kg daily for severe refractory disease 1
Special Populations and Considerations
HIV/AIDS Patients
- Antiretroviral therapy is strongly recommended to reduce recurrence of oral thrush 1
- Chronic suppressive therapy is usually unnecessary, but if required for recurrent infection, fluconazole 100 mg three times weekly 1
- Single-dose fluconazole 150 mg has shown 96.5% efficacy in palliative care patients with advanced cancer 5
Denture-Related Candidiasis
- Disinfection of the denture in addition to antifungal therapy is mandatory 1
- Failure to address denture hygiene leads to treatment failure and rapid recurrence 1
Common Pitfalls to Avoid
Do not treat asymptomatic oral colonization - this leads to unnecessary medication exposure and promotes resistance 2. Treatment is only indicated for symptomatic disease with visible lesions and patient discomfort 1.
Ensure adequate treatment duration - shorter courses (less than 7 days) have higher failure rates, particularly in immunocompromised patients 1, 2. The 7-14 day duration is evidence-based and should not be shortened 1.
Verify compliance with topical agents - troches must dissolve slowly in the mouth over 30 minutes, not be chewed or swallowed 6. Poor technique explains many treatment failures with topical therapy 3.
Consider fluconazole for patients with compliance issues - once-daily oral dosing has significantly better adherence than five-times-daily troches 3. Manual dexterity problems in elderly patients also favor systemic therapy 2.