What is the appropriate examination and treatment for a 35-year-old female with white patches on her tongue and a raw feeling, considering potential underlying conditions such as immunocompromised states, diabetes, or medication use?

White Patches on Tongue with Raw Sensation in a 35-Year-Old Female

The most likely diagnosis is oral candidiasis (thrush), which requires confirmation by scraping with KOH preparation or culture, followed by treatment with topical or systemic antifungal therapy depending on severity and underlying risk factors. 1

Immediate Examination Priorities

Visual Inspection

• Examine the tongue for white plaques that can be scraped off, revealing an erythematous base underneath—this is pathognomonic for pseudomembranous candidiasis. 2
• Look specifically at the tongue tip bilaterally, lips, palate, and buccal mucosa, as these are the most common sites for both candidal infection and burning mouth syndrome. 3
• Check for erythematous patches without white coating (erythematous candidiasis) or angular cheilitis at the corners of the mouth, which are alternative presentations of oral candidiasis. 2
• Assess for median rhomboid glossitis (a smooth, red, depapillated area in the midline of the dorsal tongue), which is usually associated with candidal infection. 4

Diagnostic Confirmation

• Perform a scraping of the white patches and prepare with KOH solution for immediate microscopic examination to visualize yeast and pseudohyphae. 1
• If KOH preparation is unavailable or negative but clinical suspicion remains high, send a culture on Sabouraud dextrose agar to identify Candida species. 5
• The raw sensation suggests either active candidal infection or secondary atrophic glossitis from nutritional deficiency. 4

Critical Risk Factor Assessment

Modifying Factors That Change Management

• Screen for diabetes mellitus with fasting glucose and HbA1c—diabetic patients have higher rates of oral candidiasis (53.6% vs 36.3% in non-diabetics) and may require more aggressive treatment. 5, 6
• Assess for immunocompromised states including HIV infection, use of corticosteroids (including inhaled steroids), chemotherapy, or other immunosuppressive medications. 1, 6
• Document any history of recent antibiotic use, which disrupts normal oral flora and predisposes to candidal overgrowth. 1
• Check for xerostomia (dry mouth) and measure salivary flow if possible—xerostomia is strongly associated with oral Candida presence (OR 9.6). 5
• Ask about use of dental prostheses, which dramatically increases risk of oral Candida (OR 25.6). 5

Laboratory Workup for Persistent or Recurrent Cases

• Order complete blood count with differential to identify anemia, which commonly causes oral burning symptoms and atrophic glossitis. 3
• Check vitamin B12, folate, iron studies (ferritin, serum iron, TIBC), as deficiencies frequently present with burning tongue and resolve with correction. 3, 4
• Measure serum albumin—low levels are associated with oral Candida presence (OR 0.41 per unit decrease). 5
• Consider thyroid function tests, as hyperthyroidism can cause tongue erythema with burning sensations. 7

Treatment Algorithm

For Confirmed Oral Candidiasis

Immunocompetent Patients:

• Start with topical therapy: clotrimazole troches 10 mg five times daily for 7-14 days, or nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days. 6
• If topical therapy fails or patient cannot tolerate it, use fluconazole 100-200 mg orally once daily for 7-14 days (200 mg loading dose on day 1, then 100 mg daily). 6, 8
• Clinical evidence should resolve within several days, but continue treatment for at least 2 weeks to decrease likelihood of relapse. 6

Diabetic or Immunocompromised Patients:

• Begin with systemic therapy: fluconazole 200 mg on day 1, then 100 mg daily for 7-14 days, as these patients are at higher risk for invasive fungal infection and treatment failure. 6
• Do NOT irrigate the ear canal or oral cavity aggressively in diabetic/immunocompromised patients, as this may predispose to invasive infection. 6
• Monitor for signs of invasive fungal infection including persistent fever, worsening symptoms despite treatment, or systemic involvement. 6

Fluconazole-Refractory Cases:

• Try itraconazole solution 200 mg daily (or higher doses), which is effective in approximately two-thirds of fluconazole-refractory cases. 6
• Consider amphotericin B oral suspension 1 mL four times daily (100 mg/mL suspension) for patients who do not respond to itraconazole. 6
• Intravenous amphotericin B 0.3 mg/kg/day may be necessary as last resort in refractory disease. 6

If Candidiasis is Excluded

Consider Primary Burning Mouth Syndrome if:

• Oral mucosa appears completely normal on examination despite burning/raw sensation. 3
• Symptoms are bilateral, continuous, and affect tongue tip, lips, or palate. 3
• Patient is perimenopausal or postmenopausal woman. 3
• All laboratory tests (CBC, B12, iron studies, glucose, thyroid) are normal. 3

Consider Nutritional Deficiency (Atrophic Glossitis) if:

• Tongue appears smooth, red, and depapillated rather than white. 4
• Laboratory testing reveals iron deficiency, B12 deficiency, folate deficiency, or low albumin. 4, 5
• Treatment involves correcting the underlying nutritional deficiency. 4

Common Pitfalls to Avoid

• Do not diagnose primary burning mouth syndrome without first excluding oral candidiasis, even if white patches are not obvious—erythematous candidiasis can present with burning and minimal visible changes. 1, 2
• Do not assume all white patches are candidiasis—leukoplakia requires biopsy to exclude premalignant changes or squamous cell carcinoma, especially in patients with tobacco/alcohol use. 4
• Do not use suppressive antifungal therapy routinely for recurrent infections, as this promotes antifungal resistance—reserve for frequent or disabling recurrences only. 6, 1
• Do not overlook medication review—many drugs cause oral burning as a side effect and may need to be discontinued or changed. 6, 7
• In patients with recurrent oral candidiasis despite appropriate treatment, strongly consider underlying immunodeficiency including HIV testing and evaluation for diabetes. 9, 1