What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, use 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

Treatment Algorithm Based on Disease Severity

Mild Disease

For patients with mild oral thrush, you have several topical options that are equally effective:

• Clotrimazole troches 10 mg administered 5 times daily for 7-14 days 2, 1
• Miconazole mucoadhesive buccal tablet 50 mg applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
• Nystatin suspension 100,000 U/mL at 4-6 mL four times daily for 7-14 days 2, 3
• Nystatin pastilles 200,000 U each, 1-2 pastilles four times daily for 7-14 days 2

When using nystatin suspension, instruct patients to swish and hold in the mouth for as long as possible before swallowing or spitting to maximize contact time with the oral mucosa. 1

Moderate to Severe Disease

Oral fluconazole 100-200 mg (3 mg/kg) daily for 7-14 days is the treatment of choice for moderate to severe oral thrush. 2, 1 Fluconazole demonstrates superior efficacy compared to topical agents and is associated with lower relapse rates in immunocompromised patients. 2 Research supports that fluconazole is significantly more effective than nystatin, with clinical cure rates of 100% versus 32% in comparative studies. 4

Fluconazole-Refractory Disease

For patients who fail fluconazole therapy after 7-14 days:

• First-line alternative: Itraconazole solution 200 mg once daily for up to 28 days 2, 1
• Second-line alternative: Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 2, 1
• Third-line options when other agents fail: Voriconazole 200 mg twice daily or amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 2
• For severe refractory disease: Intravenous echinocandin or amphotericin B deoxycholate 0.3 mg/kg daily 2

Fluconazole resistance may develop with prolonged or repeated exposure, particularly in immunocompromised patients, and certain species like C. glabrata and C. krusei demonstrate intrinsic resistance to fluconazole. 1

Special Clinical Situations

Denture-Related Candidiasis

Always disinfect the denture in addition to providing antifungal therapy. 2, 1 The denture itself serves as a reservoir for reinfection, and failure to disinfect it will result in treatment failure. 5 Use 2% chlorhexidine gluconate solution or equal parts hydrogen peroxide and water to disinfect dentures and oral hygiene aids. 5

Recurrent Infections Requiring Chronic Suppression

For patients with recurrent oral thrush who require chronic suppressive therapy:

• Fluconazole 100 mg three times weekly is recommended 2, 1
• Chronic suppressive therapy is usually unnecessary for HIV-infected patients on effective antiretroviral therapy 2
• For HIV-infected patients, initiate or optimize antiretroviral therapy to reduce recurrent infections 1

The evidence shows that continuous suppressive therapy reduces relapse rates more effectively than episodic treatment, though it carries increased risk of microbiological resistance. 2

HIV-Infected Patients

In patients with HIV, oral thrush may indicate disease progression and low CD4 counts, warranting evaluation of HIV control and consideration for antiretroviral therapy optimization. 1 Treatment with highly active antiretroviral therapy (HAART) is the most effective strategy to reduce recurrent infections. 2

Important Clinical Considerations

Underlying Predisposing Factors

Always evaluate for underlying conditions that predispose to oral thrush: 1

• Diabetes mellitus
• Immunosuppression (HIV, chemotherapy, transplant)
• Corticosteroid use (inhaled or systemic)
• Recent broad-spectrum antibiotic therapy
• Poor oral hygiene or ill-fitting dentures

Contaminated Oral Hygiene Aids

Toothbrushes and denture brushes may harbor Candida and serve as sources of reinfection; advise patients to discard or disinfect these items during treatment. 5

Alternative Single-Dose Regimen

For palliative care or hospice patients with advanced cancer who have difficulty with pill burden, a single dose of fluconazole 150 mg has demonstrated 96.5% improvement in signs and symptoms, though this is not part of standard guidelines. 6 This approach may be considered in select patients prioritizing quality of life over guideline-concordant multi-day therapy.