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Treatment of oral candidiasis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Initial management includes identifying and correcting any underlying factors that may predispose or contribute to oral candidiasis

  • 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 candidiasis
    • 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)
      • 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 miconazole oral gel regime then treat with nystatin suspension for 7 day course
      • seek specialist advice (3)
        • if inadequate response to 14 day treatment for oral thrush or
        • there are recurrent episodes of oral thrush 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 advice
                • 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 fluconazole (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 (3).

Reference:

1. Neville BA, Damm DD, Allen CM, et al. Fungal and protozoal diseases. In: Oral & maxillofacial pathology. 4th ed. Philadelphia: W.B. Saunders Company; 2015.

2. Singh A, Verma R, Murari A, Agrawal A. Oral candidiasis: An overview. Journal of Oral and Maxillofacial Pathology : JOMFP. 2014;18(Suppl 1):S81-S85.

3. Pappas PG et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50.

4. Canafax DM et al. Interaction between cyclosporine and fluconazole in renal allograft recipients.Transplantation. 1991 May;51(5):1014-8.

5. Mathis AS et al. Sex and ethnicity may chiefly influence the interaction of fluconazole with calcineurin inhibitors.Transplantation. 2001 Apr 27;71(8):1069-75.


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