From the Guidelines
The workup for thrush (oral candidiasis) should begin with a thorough clinical examination of the oral cavity, looking for characteristic white, curd-like plaques on the tongue, palate, or buccal mucosa that can be scraped off, revealing an erythematous base. The initial evaluation should focus on identifying underlying causes of thrush, such as recent antibiotic use, diabetes, or immunocompromised states like HIV, as these conditions can increase the risk of developing oral candidiasis 1. Key aspects of the workup include:
- A thorough medical history to identify potential predisposing factors
- A physical examination to assess the extent of oral involvement and look for signs of complications
- Laboratory tests, such as blood glucose monitoring or HIV testing, may be necessary in certain cases to identify underlying conditions that may be contributing to the development of thrush. First-line treatment is typically topical antifungal therapy with nystatin oral suspension (100,000 units/mL), 4-6 mL swished and swallowed four times daily for 7-14 days, or clotrimazole troches (10 mg) dissolved in the mouth five times daily for 7-14 days, as recommended by the Infectious Diseases Society of America 1. For more severe or resistant cases, oral fluconazole at a dosage of 100–200 mg daily for 7–14 days is recommended 1. Patients should be advised to maintain good oral hygiene, including regular brushing and cleaning of dentures if applicable, and to discontinue unnecessary antibiotics or optimize blood glucose control in diabetics to reduce the risk of recurrent thrush. In cases of fluconazole-refractory disease, alternative treatments such as itraconazole solution or posaconazole suspension may be considered, as outlined in the clinical practice guidelines for the management of candidiasis 1.
From the FDA Drug Label
The solution should be vigorously swished in the mouth (10 mL at a time) for several seconds and swallowed. The recommended dosage of SPORANOX ® (itraconazole) Oral Solution for oropharyngeal candidiasis is 200 mg (20 mL) daily for 1 to 2 weeks. The work up for thrush (oropharyngeal candidiasis) may involve a treatment trial with itraconazole 200 mg (20 mL) daily for 1 to 2 weeks, with clinical signs and symptoms generally resolving within several days 2.
- Key points:
- Dose: 200 mg (20 mL) daily for 1 to 2 weeks
- Administration: Swish in mouth for several seconds, then swallow
- Expected response: Clinical signs and symptoms resolve within several days
- Note: Patients may be expected to relapse shortly after discontinuing therapy.
From the Research
Thrush Workup
- Thrush, also known as vulvovaginal candidiasis, is a common fungal infection that affects up to 5% of women 3.
- The diagnosis of thrush is typically confirmed by the presence of symptoms and a positive culture and/or microscopy 3.
- Treatment options for thrush include antifungal medications, such as fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole 3, 4, 5, 6, 7.
- Voriconazole is an effective treatment for invasive aspergillosis, candidiasis, and other fungal infections, but it has unpredictable pharmacokinetics and can cause adverse effects such as periostitis, alopecia, and skin cancers 4, 5.
- Posaconazole is another antifungal medication that is effective in preventing invasive fungal infections in high-risk patients with hematological malignancies, but it can cause liver function test abnormalities 6.
- Some analgesic drugs, such as ibuprofen, have been shown to have antifungal activity against Candida spp. isolates, and may be used in combination with antifungal medications to enhance their effectiveness 7.
Treatment Options
- Antifungal medications, such as fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole, are commonly used to treat thrush 3, 4, 5, 6, 7.
- Topical antifungals, such as clotrimazole and miconazole, may also be effective in treating thrush 3.
- Combination therapy, such as using an antifungal medication with an analgesic drug, may be effective in enhancing the treatment of thrush 7.
Adverse Effects
- Antifungal medications, such as voriconazole, can cause adverse effects such as periostitis, alopecia, and skin cancers 4, 5.
- Posaconazole can cause liver function test abnormalities 6.
- Analgesic drugs, such as ibuprofen, may cause adverse effects such as gastrointestinal upset and renal impairment 7.