treatment of oral candidiasis

Last edited 06/2021 and last reviewed 10/2023

Initial management includes identifying and correcting any underlying factors that may predispose or contribute to oral candidosis
  • exclude any deficiency states (iron, folate and vitamins B12 and C), diabetes and any immunodeficiencies
    • this condition is uncommon in people other than infants, denture wearers, and the elderly
  • identify any drugs which might be the cause and if practical, substituted for an alternative
  • in denture‐associated erythematous candidosis
    • check for the adequacy of the dentures
    • evaluate oral and denture hygiene measures and make necessary corrections if required
    • avoid nocturnal denture wearing (1,2)

If underlying predisposing factors cannot be corrected, pharmacological treatment is indicated

  • treatment involves topical or systemic antifungals
  • management options vary with respect to patient population:

    • oral candidiasis in children
      • exclude risk factors for candidiasis (1,2,3)
      • topical antifungal treatment
        • first line therapy
          • miconazole oral gel first-line for 7 days
            • note that this medication is unlicensed for use in a child aged younger than 4 months (or 5-6 months for an infant born pre-term)
          • an alternative is oral nystatin suspension for 7 days
            • note that this medication is unlicensed for use in neonates
      • if persistent oral candidiasis after 7 day treatment regime (and adequate adherence to regime)
        • if evidence of partial response to miconazole oral gel then extension of treatment for a further 7 day course
        • if minimal or no effect from miconazol oral gel regime then treat with nystatin suspension for 7 day course
      • seek specialist advice
        • if inadequate response to 14 day treatment for oral thrush or
        • there are recurrent episodes of oral thrush (3) or
        • a clinical suspicion of immunosuppression

    • oral candidiasis in adults and young people
      • oral candidiasis is uncommon in people other than infants, denture wearers, and the elderly. In otherwise healthy people, it may be the first presentation of an undiagnosed risk factor.
      • Prescribe antifungal treatment.
        • If the infection is mild and localized, prescribe topical antifungal treatment for 7 days.
          • miconazole oral gel is  first-line therapy
          • If miconazole is unsuitable, offer nystatin suspension.
        • If the infection is extensive or severe infection, consider one of the following: 
          • oral fluconazole 50 mg a day for 7 days or
          • seek specialist advice or refer to an oral surgeon (3)
          • follow up people who have extensive or severe oral candidiasis (requiring oral fluconazole) after 7 days
            • if complete resolution of infection then stop treatment
            • if there has not been complete resolution of the infection then various options are appropriate (3):
                • extension of the course of fluconazole for a further 7 days (refer to an oral surgeon if the infection persists after this)
                • take an oral swab in order to identify the causative organism
                • seek further advicce
                  • either seek specialist advice or
                  • undertake specialist referral (to an oral surgeon)
              • when making this decision then the clinician must consider
                • a) severity of infection - there should be a low threshold for early referral if infection is severe (3)
                • b) the level of immunocompromise
                • c) response to first-line therapy. 

    • oral candidiasis in immunosuppressed adults
      • mild, localized oral candidiasis
        • miconazole oral gel first-line for 7 days
        • nystatin suspension for 7 days is an alternative
      • if severe and extensive infection then consider
          • systemic treatment with oral fluclonazole (check the summary of product characteristics before prescribing) and/or
          • seeking specialist advice
        • be aware of the potential interactions of systemic antifungal therapy with medication prescribed
          • for example fluconazole can increase ciclosporin or tacrolimus levels if prescribed concurrently with either of these agents (4,5)
        • seek specialist advice if patient on chemotherapy regime
      • if there is a concern that oral candidiasis may be related to immunosuppression caused by disease-modifying anti-rheumatic drugs (DMARDS)
        • seek specialist advice
        • ensure monitoring blood tests are undertaken

Notes:                        

  • general principles for use of systemic agents such as fluconazole, ketoconazole, and itraconazole (1)
    • these may be used in the following groups
      • patients who have candidiasis refractory to topical therapy
      • patients intolerant of topical agents
      • patients at high risk of developing systemic infection (1,2)

  • oral candidiasis
    • uncommon in people other than infants, denture wearers, and the elderly
    • it may be the first presentation of an undiagnosed risk factor

  • evidence from randomised controlled trials that miconazole and fluconazole increased clinical cure of oropharyngeal candidiasis in immunocompetent and immunocompromised infants and children when compared with nystatin (6,7).

Reference:

Related pages:

HIV positive patients