Treatment Options for Thrush (Oral Candidiasis)
For mild oral thrush, 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, oral fluconazole 100-200 mg daily for 7-14 days is the recommended treatment. 1
Treatment Algorithm by Disease Severity
Mild Disease (First-Line Options)
- Clotrimazole troches 10 mg five 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 1
Mild Disease (Alternative Options)
- Nystatin suspension (100,000 U/mL) 4-6 mL four times daily for 7-14 days 1
- Nystatin pastilles (200,000 U each) 1-2 pastilles four times daily for 7-14 days 1
Moderate to Severe Disease
- Oral fluconazole 100-200 mg daily for 7-14 days 1
- This represents the most effective systemic approach with high-quality evidence supporting its use 1
Refractory Disease Management
Fluconazole-Refractory Cases (First-Line)
- Itraconazole solution 200 mg once daily for up to 28 days 1
- Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
Fluconazole-Refractory Cases (Alternative Options)
- Voriconazole 200 mg twice daily 1
- Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 1
Severe Refractory Disease Requiring IV Therapy
- 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) 1
- Intravenous amphotericin B deoxycholate 0.3 mg/kg daily 1
Special Considerations
Chronic Suppressive Therapy
- Usually unnecessary for most patients 1
- If required for recurrent infection: fluconazole 100 mg three times weekly 1
HIV-Infected Patients
- Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1
- This addresses the underlying immunosuppression that predisposes to thrush 1
Denture-Related Candidiasis
- Disinfection of the denture in addition to antifungal therapy is required 1
- Failure to address the denture as a reservoir will result in treatment failure 1
Important Clinical Pitfalls
Avoid using azoles in patients with prior azole prophylaxis due to increased risk of resistance 1. In these cases, consider non-azole alternatives from the outset.
Single-dose fluconazole 150 mg (commonly used for vaginal candidiasis) 2, 3, 4, 5 has shown efficacy in some palliative care settings for oral thrush 6, but this is not the standard guideline-recommended approach for oral candidiasis. The 2016 IDSA guidelines clearly recommend 7-14 days of therapy for oral thrush 1.
Candida krusei should be considered inherently resistant to fluconazole 2, requiring alternative agents if this species is identified.
The strength of evidence for topical agents (clotrimazole, miconazole) in mild disease is high-quality 1, while systemic fluconazole for moderate-severe disease also has high-quality evidence 1. The 2016 IDSA guidelines represent the most current authoritative source and supersede the 2009 recommendations 1.