Treatment of oral candidiasis

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.