Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

oral candidiasis

1st line – topical antifungal

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ACUTE
|
oral candidiasis
|
mild to moderate disease
1st line – 

topical antifungal

Mild to moderate disease includes patients with focal tissue involvement and minimal symptoms. Treatment is recommended immediately after diagnosis, and may involve azole antifungal agents (e.g., clotrimazole, miconazole), a topical polyene (i.e., nystatin), or gentian violet.[17]​​[54]

Short courses of topical antifungal therapy rarely result in adverse effects.

Nystatin suspension has a high sucrose content and its frequent use, especially in a xerostomic patient, may increase the risk of dental caries.[62]

Primary options

clotrimazole oropharyngeal: 10 mg orally (dissolved in the mouth) five times daily for 14 days

OR

miconazole oropharyngeal: 50 mg buccally (to mucosa above incisor tooth) once daily for 14 days

OR

nystatin: (100,000 units/mL) 4-6 mL orally (swish around mouth and retain for as long as possible before swallowing) four times daily for 7-14 days

OR

gentian violet topical: (1%) apply to the affected area(s) once daily

Consider – aggressive disinfection of removable dentures

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ACUTE
|
oral candidiasis
|
mild to moderate disease
Consider – 

aggressive disinfection of removable dentures

Treatment recommended for SOME patients in selected patient group

For denture-related disease, aggressive disinfection of the dentures for definitive cure is often recommended.[59] However, there is weak evidence in support of soaking the dentures in effervescent tablets or enzymatic solutions alone. Manually brushing the dentures with paste has been found to be more efficacious at removing plaque and killing microbes compared to inactive treatment.[60]

Published guidelines emphasize careful daily removal of bacterial biofilm on dentures by soaking and manual brushing with an effective nonabrasive denture cleaner as an effective method for controlling denture stomatitis. They also recommend not wearing dentures continuously (i.e., 24 hours per day), as this can also reduce the risk of denture stomatitis.[58][61]

1st line – systemic antifungal treatment

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ACUTE
|
oral candidiasis
|
severe disease
1st line – 

systemic antifungal treatment

Severe disease includes patients with generalized tissue involvement, pain, and burning. For these patients, especially in patients with HIV, who may relapse sooner with a topical agent, treatment with systemic azoles (e.g., fluconazole tablets, itraconazole oral solution, or posaconazole oral suspension) is recommended.[17]​​[54] Infectious Diseases Society of America guidelines recommend the use of fluconazole in severe disease; other azoles are reserved for fluconazole-resistant cases.[54] However, US guidelines for opportunistic infections in people with HIV recommend fluconazole as first-line treatment but recognize other azoles as acceptable options.​[17]​

Itraconazole oral solution and posaconazole oral suspension are both as effective as fluconazole tablets but have more drug-drug interactions. Posaconazole oral suspension is better tolerated than itraconazole oral solution.​[17]​

Ketoconazole and itraconazole capsules (but not itraconazole suspension) are less effective than fluconazole because of their more variable absorption and should be second-line alternatives.[17]​​[54]

Fluconazole-refractory oropharyngeal candidiasis will respond to posaconazole oral suspension in 75% of patients, while itraconazole oral solution is considered an alternative treatment.[17]​​[54]

The most common adverse effects associated with the use of posaconazole include headache, fever, nausea, vomiting, and diarrhea.[63] Ketoconazole may cause severe liver injury and adrenal insufficiency. In July 2013, the US Food and Drug Administration recommended that oral ketoconazole should only be used for life-threatening fungal infections where alternative treatments are not available or tolerated, and when the potential benefits of treatment outweigh the risks. Its use is contraindicated in patients with liver disease. If used, liver and adrenal function should be monitored before and during treatment.[64]

Patients may experience gastrointestinal upset with oral azole treatment, and periodic monitoring for hepatotoxicity is recommended for treatment >21 days.​[17]​

Primary options

fluconazole: 200 mg orally on day one, followed by 100-200 mg once daily for at least 2 weeks

OR

posaconazole: initial therapy: 100 mg orally (suspension) twice daily on day one, followed by 100 mg once daily for at least 13 days; refractory to itraconazole/fluconazole: 400 mg orally (suspension) twice daily

OR

itraconazole: initial therapy: 200 mg orally (solution) once daily for at least 2 weeks; refractory to fluconazole: 100 mg orally (solution) twice daily

Secondary options

ketoconazole: 200 mg orally once daily for at least 2 weeks

More

OR

itraconazole: 200 mg orally (capsule) once daily for at least 2 weeks

More

Consider – aggressive disinfection of removable dentures

Back
ACUTE
|
oral candidiasis
|
severe disease
Consider – 

aggressive disinfection of removable dentures

Treatment recommended for SOME patients in selected patient group

For denture-related disease, aggressive disinfection of the dentures for definitive cure is often recommended.[59] However, there is weak evidence in support of soaking the dentures in effervescent tablets or enzymatic solutions alone. Manually brushing the dentures with paste has been found to be more efficacious at removing plaque and killing microbes compared to inactive treatment.[60]

Published guidelines emphasize careful daily removal of bacterial biofilm on dentures by soaking and manual brushing with an effective nonabrasive denture cleaner as an effective method for controlling denture stomatitis. They also recommend not wearing dentures continuously (i.e., 24 hours per day), as this can also reduce the risk of denture stomatitis.[58][61]

2nd line – alternative antifungal treatment

Back
ACUTE
|
oral candidiasis
|
severe disease
2nd line – 

alternative antifungal treatment

Further alternative compounds for patients with azole-resistant strains include anidulafungin, caspofungin, micafungin, voriconazole, or amphotericin-B.[17]​​[54] Resistance to caspofungin in albicans and non-albicans strains has been reported.[65][66]

Intravenous amphotericin-B is usually reserved for progressive potentially life-threatening fungal infections. Amphotericin-B oral suspension may also be used when treatment with itraconazole has failed; however, it is not available in the US.​[17]​[54] 

If intravenous antifungal therapy is being considered, the patient is referred to an infectious disease specialist for management.

Primary options

anidulafungin: 200 mg intravenously as a loading dose on day one, followed by 100 mg once daily

OR

caspofungin: 50 mg intravenously once daily

OR

micafungin: 150 mg intravenously once daily

OR

voriconazole: 200 mg orally twice daily

Secondary options

amphotericin B deoxycholate: consult specialist for guidance on dose

OR

amphotericin B lipid complex: consult specialist for guidance on dose

angular cheilitis

1st line – antifungal cream or ointment

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ACUTE
|
angular cheilitis
1st line – 

antifungal cream or ointment

Management of angular cheilitis involves the use of topical antifungal agents and sometimes topical corticosteroids. See Angular cheilitis.

ONGOING

severely immunocompromised: prophylactic-therapy

1st line – suppressive therapy

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ONGOING
|
severely immunocompromised: prophylactic-therapy
1st line – 

suppressive therapy

Prophylaxis with antifungal agents may be used to prevent local infection and systemic candidal involvement in patients undergoing radiation or chemotherapeutic cancer treatment, or among patients who have had a bone marrow or organ transplant. [ Cochrane Clinical Answers logo ] There is also some evidence that among very preterm and very low birth weight infants, prophylaxis with oral/topical nonabsorbed antifungal agents reduces the risk for invasive fungal infection.[52] Evidence suggests that antifungal prophylactic drugs absorbed from the gastrointestinal tract (e.g., fluconazole) prevent oral candidiasis in patients receiving treatment for cancer.[44][45][46] 

Routine primary prophylaxis is not recommended among patients with advanced HIV infection due to the risk of drug-resistant Candidastrains and significant drug-drug interactions. The administration of antiretroviral therapy and immune restoration among patients living with HIV is deemed most effective in preventing oropharyngeal candidiasis.​[17]​

Most HIV specialists do not recommend secondary prophylaxis of recurrent oropharyngeal candidiasis unless the patient has frequent or severe recurrences.[17]​ In such cases, a daily dose of fluconazole is recommended.[17]​​[54] [ Cochrane Clinical Answers logo ]  

Continuous fluconazole therapy (three times weekly dosing) compared with episodic fluconazole treatment has been shown to be more effective in lowering the number of episodes of recurrences among patients with CD4 counts <150 cells/mm³.[67] There are insufficient data to make recommendations concerning continuous versus intermittent therapy for the use of prophylactic antifungals in patients with diabetes.[15]

The use of continuous suppressive therapy increases the number of Candida isolates with an increased fluconazole minimum inhibitory concentration, but it does not increase the likelihood of developing an infection that does not respond to fluconazole.[48]

Patients may experience hepatotoxicity with >7 to 10 days of systemic azole treatment.[16]

Primary options

fluconazole: 100 mg orally once daily or three times weekly

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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