What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, start with clotrimazole troches 10 mg five times 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 Oral Thrush

• Clotrimazole troches 10 mg five times daily for 7-14 days is the preferred first-line therapy, offering superior convenience and comparable efficacy to other topical agents 1
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily to the mucosal surface over the canine fossa for 7-14 days provides a more convenient once-daily alternative 1
• Nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days is an option, though it has lower efficacy (32-54% cure rates) compared to fluconazole (100% cure rates) and requires swishing in the mouth as long as possible before swallowing 1, 2
• Nystatin pastilles 1-2 tablets (200,000 units each) four times daily for 7-14 days can be used as an alternative formulation 2

Moderate to Severe Oral Thrush

• Oral fluconazole 100-200 mg daily for 7-14 days is the gold standard treatment, demonstrating superior efficacy with strong recommendation and high-quality evidence 1, 2
• This regimen achieves significantly higher clinical cure rates than topical agents and is preferred over nystatin for immunocompromised patients 2
• Treatment should continue until clinical resolution of symptoms 1

Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole 400 mg (6 mg/kg) daily is the preferred alternative 1
• Intravenous echinocandins (caspofungin 70 mg loading dose then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg daily) are effective alternatives 3, 1
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily is a less preferred option 1

Fluconazole-Refractory Disease

When standard fluconazole therapy fails after 7-14 days, escalate to alternative systemic agents:

• Itraconazole solution 200 mg once daily for up to 28 days is effective in approximately two-thirds of fluconazole-refractory cases 1, 2
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
• Voriconazole 200 mg twice daily 1
• Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 1

Special Clinical Situations

Denture-Related Candidiasis

• Denture disinfection must accompany any antifungal therapy 1, 2
• Remove dentures at night and clean thoroughly 1
• Systemic antifungal therapy is typically required in addition to local measures 1

HIV-Infected Patients

• Antiretroviral therapy is more important than antifungal choice for reducing recurrence rates and should be strongly emphasized 1, 2
• These patients may require longer treatment courses or higher doses of antifungal medications 1
• For recurrent infections, fluconazole 100 mg three times weekly for chronic suppressive therapy is recommended 1, 2

Esophageal Involvement

• Topical agents like nystatin are inadequate when esophageal candidiasis is present 2
• Systemic therapy with fluconazole 200-400 mg (3-6 mg/kg) daily for 14-21 days is required 3
• Patients should swallow rather than spit out oral suspensions to treat potential esophageal involvement 2

Important Clinical Caveats

• Topical agents have suboptimal tolerability and significantly lower efficacy compared to fluconazole, with nystatin achieving only 32-54% clinical cure rates versus 100% with fluconazole 2
• Treatment duration should extend for at least 48 hours after symptoms disappear and cultures confirm eradication 2
• Patient compliance is significantly better with once-daily fluconazole compared to multiple-daily-dosing regimens like clotrimazole troches 4
• Nystatin should not be first-line for moderate-to-severe disease or immunocompromised patients due to inferior efficacy 2
• For proper nystatin administration, patients must swish the suspension thoroughly for at least 2 minutes, ensuring contact with all affected areas before swallowing 2