What is the recommended treatment for oral candidiasis?

Treatment for Oral Candidiasis

For mild oral candidiasis, use clotrimazole troches 10 mg five times daily OR miconazole mucoadhesive buccal 50-mg tablet once daily for 7-14 days; for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1

Treatment Algorithm by Disease Severity

Mild Disease (First-Line Options)

Topical therapy is appropriate and highly effective for mild oral candidiasis. 1, 2

• Clotrimazole troches 10 mg five times daily for 7-14 days (strong recommendation; high-quality evidence) 1, 2
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily to the mucosal surface over the canine fossa for 7-14 days (strong recommendation; high-quality evidence) 1, 2

Mild Disease (Alternative Options)

If first-line topical agents are unavailable or not tolerated:

• Nystatin suspension (100,000 U/mL) 4-6 mL four times daily for 7-14 days (strong recommendation; moderate-quality evidence) 1, 2, 3
• Nystatin pastilles (200,000 U each) 1-2 pastilles four times daily for 7-14 days (strong recommendation; moderate-quality evidence) 1

Common pitfall: Nystatin requires longer contact time with oral mucosa and more frequent dosing than clotrimazole or miconazole, which may reduce patient adherence. 1

Moderate to Severe Disease

Systemic therapy is required for moderate to severe oral candidiasis. 1, 2

• Oral fluconazole 100-200 mg daily for 7-14 days (strong recommendation; high-quality evidence) 1, 2, 4
• Clinical improvement typically occurs within 5-7 days 2
• Fluconazole can be taken with or without food 4

Refractory Disease Management

Fluconazole-Refractory Oral Candidiasis

For patients who fail fluconazole therapy, use 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

Additional alternatives for refractory disease include:

• Voriconazole 200 mg twice daily (strong recommendation; moderate-quality evidence) 1, 2
• Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily (strong recommendation; moderate-quality evidence) 1, 2

Important caveat: Fluconazole resistance predominantly occurs after repeated and long-term azole exposure, particularly in immunosuppressed patients with low CD4 counts. 1 Non-albicans species, especially C. glabrata, are more likely to be fluconazole-resistant. 1

Severe Refractory Disease

For patients who cannot tolerate or fail oral alternatives:

• 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) (weak recommendation; moderate-quality evidence) 1
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily (weak recommendation; moderate-quality evidence) 1

Special Populations and Circumstances

Denture-Related Candidiasis

Disinfection of the denture is mandatory in addition to antifungal therapy. 1, 2 Without denture disinfection, antifungal treatment alone will fail due to recolonization from the contaminated prosthesis. 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections (strong recommendation; high-quality evidence) 1, 2
• Oral candidiasis most commonly occurs when CD4 counts fall below 200 cells/μL 1
• The advent of effective antiretroviral therapy has dramatically reduced the prevalence of oropharyngeal candidiasis and refractory disease 1

Recurrent Infections

Chronic suppressive therapy is usually unnecessary. 1, 2 However, if required for patients with frequent recurrences:

• Fluconazole 100 mg three times weekly (strong recommendation; high-quality evidence) 1, 2

Critical point: Address the underlying cause of immunosuppression rather than relying on chronic suppression. 1

Monitoring and Expected Response

• Clinical response to topical therapy should be evident within 48-72 hours 2
• Treatment should continue for at least 2 weeks to decrease the likelihood of relapse 1, 4
• Oral cultures are generally not needed for diagnosis or management of uncomplicated cases 2

Key Clinical Pitfalls to Avoid

1. Do not use fluconazole capsules or ketoconazole when itraconazole solution is available for refractory disease – itraconazole solution is superior to capsules due to local mucosal effects in addition to systemic absorption 1

2. Do not assume all topical agents are equivalent – clotrimazole troches and miconazole buccal tablets have higher quality evidence and better patient adherence than nystatin 1

3. Do not overlook denture disinfection – failure to address contaminated dentures is a common cause of treatment failure 1, 2

4. Do not prescribe chronic suppressive therapy routinely – it is unnecessary for most patients and should only be used for those with documented recurrent infections despite addressing underlying causes 1, 2