What is the treatment for oral candidiasis in a patient using inhalational corticosteroids (inhalers)?

Treatment of Oral Candidiasis Due to Inhaled Corticosteroids

For oral candidiasis caused by inhaled corticosteroids, start with topical therapy using clotrimazole lozenges 10 mg five times daily or miconazole buccal tablets 50 mg once daily for 7-14 days for mild disease, but escalate immediately to oral fluconazole 100-200 mg daily for 7-14 days if the infection is moderate to severe. 1

Initial Treatment Strategy

Mild Disease (Limited Oral Involvement)

• Topical agents are first-line for mild oropharyngeal candidiasis: clotrimazole lozenges 10 mg five times daily for 7-14 days 1
• Alternative topical option: miconazole buccal tablets 50 mg once daily for 7-14 days 1
• Nystatin suspension (100,000 U/mL) 4-6 mL four times daily or nystatin tablets (200,000 U each) four times daily for 7-14 days can be used, though these are less preferred due to tolerability issues 2, 3

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days is the treatment of choice 1, 4
• For more severe presentations or suspected esophageal involvement, increase to fluconazole 200-400 mg daily for 14-21 days 5, 2, 4
• Clinical response typically occurs within several days, but the full treatment course must be completed 1

Management of Fluconazole-Refractory Disease

If the patient fails to respond to fluconazole (which can occur with prior azole exposure from inhaled steroid use), escalate systematically:

First-Line Alternatives for Refractory Disease

• Itraconazole oral solution 200 mg daily for 14-21 days (64-80% response rate in refractory cases) 5, 1, 6
• Voriconazole 200 mg twice daily (oral or IV) for 14-21 days 5, 1

Second-Line Alternatives

• Posaconazole suspension 400 mg twice daily (~75% efficacy in refractory cases) 5, 1
• Echinocandins for severe refractory cases: micafungin 150 mg daily, caspofungin 70 mg loading dose then 50 mg daily, or anidulafungin 200 mg daily 5, 2, 1

Critical Prevention Measures

The most important intervention is proper inhaler technique to prevent recurrence:

• Instruct patients to rinse mouth thoroughly with water and spit after each inhaled corticosteroid use 7
• Use a spacer device with metered-dose inhalers to reduce oropharyngeal deposition 7
• Consider switching to lower doses of inhaled corticosteroids if clinically feasible 8

Important Clinical Pitfalls

Risk factors that increase likelihood of oral candidiasis in inhaled steroid users include:

• Higher doses of inhaled corticosteroids 8
• Concurrent use of oral corticosteroids 8
• Concurrent antibiotic use 8
• Diabetes mellitus 8
• Decreased salivary IgA levels 9

Avoid these common mistakes:

• Do not use topical agents alone for significant or moderate-to-severe infections—they have suboptimal efficacy 1
• Do not use ketoconazole due to hepatotoxicity and drug interactions 1
• Do not use echinocandins as first-line for azole-susceptible disease due to parenteral administration requirements and cost 1
• Do not assume all oral candidiasis is mild—assess for dysphagia or odynophagia suggesting esophageal involvement, which requires higher fluconazole doses (200-400 mg daily) 5, 4

Monitoring and Follow-Up

• Clinical improvement should occur within 48-72 hours of starting systemic therapy 4
• If no improvement within 1 week, consider azole resistance and change antifungal medication 4
• For recurrent infections despite proper inhaler technique, chronic suppressive therapy with fluconazole 100-200 mg three times weekly may be necessary 5, 2, 4