Treatment of Oral Thrush (Candidiasis)
For moderate to severe oral thrush, oral fluconazole 100-200 mg daily for 7-14 days is the most effective first-line treatment, while mild cases can be treated with topical clotrimazole troches or nystatin. 1, 2
Treatment Algorithm Based on Disease Severity
Mild Oral Thrush
- Clotrimazole troches 10 mg five times daily for 7-14 days are recommended as first-line topical therapy 1, 2
- 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 equally effective alternatives 1, 3
- Miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days is another option 2
Moderate to Severe Oral Thrush
- Oral fluconazole 100-200 mg (3 mg/kg) daily for 7-14 days is superior to topical therapy and should be used for all moderate to severe cases 1, 2
- Fluconazole demonstrates better clinical cure rates, lower colonization at end of therapy, and reduced relapse rates compared to clotrimazole troches 4
- Patient compliance is significantly better with once-daily fluconazole versus five-times-daily clotrimazole 4
Management of Fluconazole-Refractory Disease
When patients fail to respond to fluconazole, escalate therapy systematically:
Second-Line Oral Agents
- Itraconazole oral solution 200 mg daily for 7-14 days achieves 64-80% response rates in fluconazole-refractory cases 1, 2, 5
- The solution should be vigorously swished in the mouth (10 mL at a time) for several seconds before swallowing 5
- For patients unresponsive to standard dosing, increase to itraconazole 100 mg (10 mL) twice daily 5
Alternative Azoles for Refractory Cases
- Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days achieves approximately 75% efficacy 1, 2
- Voriconazole 200 mg twice daily (oral or IV) for 14-21 days is effective when other azoles fail 1, 2
Parenteral Therapy for Severe Refractory Disease
- Echinocandins are preferred for severe refractory cases: micafungin 150 mg daily, caspofungin 50 mg daily (after 70-mg loading dose), or anidulafungin 200 mg daily 1, 2
- Amphotericin B deoxycholate 0.3-0.7 mg/kg daily IV is a less preferred alternative due to toxicity 1, 2
Special Clinical Situations
Denture-Related Candidiasis
- Disinfection of dentures in addition to antifungal therapy is mandatory for definitive cure 1, 2, 6
- Antifungal therapy alone without proper denture hygiene will result in treatment failure 2, 6
HIV-Infected Patients
- Antiretroviral therapy should be initiated or optimized to reduce recurrent infections, as this is more effective than chronic antifungal suppression alone 1, 2
- For recurrent infections despite adequate antiretroviral therapy, suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 1, 2, 6
- Chronic daily suppressive therapy is usually unnecessary and should be avoided to reduce resistance development 1
Patients Unable to Tolerate Oral Medications
- Intravenous fluconazole 400 mg (6 mg/kg) daily, amphotericin B deoxycholate 0.3-0.7 mg/kg daily, or an echinocandin should be used 1
Critical Clinical Pitfalls to Avoid
Duration of Therapy
- Continue treatment for the full 7-14 day course even if symptoms resolve within 2-3 days, as premature discontinuation leads to relapse 2, 6
Diagnostic Testing
- Oropharyngeal fungal cultures are of little clinical benefit because many individuals have asymptomatic Candida colonization, and treatment frequently does not result in microbiological cure 2, 6
- Base treatment decisions on clinical presentation rather than culture results 2
Risk Factors for Azole Resistance
- Azole-refractory infections are significantly more common in patients with prior azole exposure and severe immunocompromise 2, 6
- Consider non-azole therapy earlier in these high-risk populations 2