What are the symptoms and treatment options for thrush?

Symptoms and Treatment of Thrush

Symptoms of Thrush

Thrush presents differently depending on the anatomical location affected, with vulvovaginal candidiasis being the most common form in women, characterized by pruritus, erythema, and white discharge.

Vulvovaginal Candidiasis (Vaginal Thrush)

• Pruritus (itching) is the hallmark symptom, typically worsening premenstrually 1, 2
• Vulvovaginal erythema (redness) and inflammation, particularly at the vaginal introitus 1, 2
• White, thick, non-odorous vaginal discharge (often described as "cottage cheese-like") 1, 3
• Burning sensation and external dysuria (pain with urination when urine contacts inflamed vulvar tissue) 1, 3
• Vaginal pH remains normal (<4.5), which distinguishes it from bacterial vaginosis or trichomoniasis 1, 4
• Important caveat: Less than 50% of women with genital pruritus actually have candidiasis, so confirmation is essential 2

Oral Thrush (Oropharyngeal Candidiasis)

• White plaques on the tongue, buccal mucosa, or palate that can be scraped off 1
• Soreness or burning in the mouth 1
• Difficulty eating or speaking in severe cases 1
• Altered taste or loss of taste 1

Laryngeal Thrush (Rare)

• Hoarseness is always present and is the primary symptom 5
• Pain may be present inconsistently, but notably no dysphagia or odynophagia (unlike other upper aerodigestive tract candidiasis) 5
• Often misdiagnosed for an average of 6 months before correct identification 5

Skin/Groin Thrush (Candidal Intertrigo)

• Erythematous rash in skin folds (groin, under breasts, between fingers) 1, 6
• Maceration and satellite lesions at the periphery of the rash 1
• Pruritus and burning in affected areas 6

Treatment of Thrush

Uncomplicated Vulvovaginal Candidiasis

For uncomplicated vaginal thrush, short-course topical azoles (1-3 days) or single-dose oral fluconazole 150 mg are equally effective, with cure rates of 80-90%. 1

Topical Intravaginal Options (all equally effective):

• Clotrimazole: 1% cream 5g for 7-14 days, OR 100mg tablet for 7 days, OR 500mg tablet single dose 1
• Miconazole: 2% cream 5g for 7 days, OR 200mg suppository for 3 days 1
• Terconazole: 0.8% cream 5g for 3 days, OR 80mg suppository for 3 days 1
• Butoconazole: 2% cream 5g for 3 days (67% therapeutic cure rate at 30 days) 1, 7

Oral Option:

• Fluconazole 150 mg single oral dose (preferred for convenience and equivalent efficacy) 1

Important note: Oil-based creams and suppositories may weaken latex condoms and diaphragms 1

Complicated Vulvovaginal Candidiasis

Complicated cases (severe symptoms, non-albicans species, immunosuppression, diabetes, pregnancy, or recurrent infections) require extended therapy for >7 days. 1

• Use any topical azole for 7-14 days instead of short-course therapy 1
• Oral fluconazole can be used but may require multiple doses 1

Fluconazole-Resistant Vaginal Candidiasis

For cases not responding to fluconazole, boric acid 600 mg intravaginal capsules daily for 14 days is the first-line alternative, particularly effective against C. glabrata. 1, 8

Treatment Algorithm for Resistant Cases:

1. First-line alternative: Boric acid 600mg vaginal capsules daily × 14 days 1, 8
2. Second-line: Nystatin 100,000 units intravaginal suppository daily × 14 days 1, 8
3. Third-line: Topical flucytosine 17% cream ± amphotericin B 3% cream daily × 14 days 8

Critical diagnostic step: Obtain vaginal culture to identify species, as C. glabrata and C. krusei are often azole-resistant 8, 2

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

Recurrent thrush requires induction therapy followed by maintenance suppression for 6 months. 1, 8

Treatment Protocol:

1. Induction: 10-14 days of topical or oral azole therapy 1, 8
2. Maintenance (choose one):
   • Fluconazole 150 mg orally weekly × 6 months 1, 8
   • Ketoconazole 100 mg daily 1
   • Itraconazole 100 mg every other day 1
   • Daily topical azole 1

Warning: Without maintenance therapy, recurrence rates reach 40-50% 8

Oral Thrush Treatment

• Nystatin oral suspension 100,000 units four times daily × 1 week 1
• Miconazole oral gel 5-10 mL held in mouth after food four times daily × 1 week 1
• For systemic or severe cases, oral fluconazole may be required 1

Groin/Skin Candidiasis

Topical azole antifungals (clotrimazole, miconazole) are first-line treatment for candidal intertrigo, with no single agent superior to others. 1, 6

• Apply topical azole (clotrimazole, miconazole, or nystatin) to affected area 1, 6
• Keep area dry—this is equally important as medication 1
• For refractory cases, consider oral fluconazole 6

Laryngeal Thrush

• Oral fluconazole with removal of predisposing factors (inhaled steroids, antibiotics) 5
• All reported cases responded readily to this approach 5

Common Pitfalls and Caveats

Diagnostic Errors

• Self-diagnosis is unreliable: Only 50% of women with genital pruritus have candidiasis 1, 2
• Confirm diagnosis microscopically: Look for yeast or pseudohyphae on KOH preparation before treating 1, 4
• Check vaginal pH: Normal pH (<4.5) supports candidiasis; elevated pH suggests bacterial vaginosis or trichomoniasis 1, 4

Treatment Mistakes

• Do NOT treat asymptomatic colonization: 10-20% of women harbor Candida without symptoms 1
• Do NOT routinely treat sexual partners unless male partner has symptomatic balanitis (erythema and pruritus on glans) 1, 6
• Avoid unnecessary prophylaxis in low-risk populations 1
• Do NOT use oral azoles during pregnancy—only topical agents are safe 1, 2

Resistance Considerations

• Suspect non-albicans species (especially C. glabrata) if treatment fails 8, 2
• C. glabrata is resistant to usual azole dosages and requires boric acid or high-dose fluconazole (800 mg/day × 2-3 weeks) 8, 2
• C. krusei is resistant to all triazoles 2
• Obtain culture with species identification for any recurrent or treatment-resistant case 8, 2

Special Populations

• Pregnancy: Use only topical azoles for 7 days; oral fluconazole is contraindicated 1, 2
• Immunosuppressed patients: May require longer treatment courses and maintenance therapy 1
• Diabetics: Control blood glucose to reduce recurrence risk 2

Follow-Up

• Return only if symptoms persist after 3 days or recur within 2 months 1
• Routine follow-up is unnecessary for uncomplicated cases that respond to treatment 1