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

infectious etiology

1st line – topical miconazole

Back
ACUTE
|
infectious etiology
|
no concurrent use of warfarin, phenytoin, or sulfonylureas
1st line – 

topical miconazole

Topical miconazole is used to treat Candida after meals and at bedtime.[2]

It is also effective against mixed infections because it has gram-positive bacteriostatic action.

Miconazole is absorbed and may potentiate the action of warfarin, phenytoin, and sulfonylureas; thus, topical nystatin or amphotericin-B lozenges should therefore be tried first in patients taking these drugs.[13][23][24]

Patients on chronic corticosteroid inhaler therapy are recommended to rinse the mouth after inhaler treatment, to reduce the risk of recurrent Candida infection.[10]

Primary options

miconazole topical: children and adults: (2%) apply to the affected area(s) twice daily for 7-14 days

Consider – topical antibacterial

Back
ACUTE
|
infectious etiology
|
no concurrent use of warfarin, phenytoin, or sulfonylureas
Consider – 

topical antibacterial

Treatment recommended for SOME patients in selected patient group

Topical mupirocin or a polymyxin-containing preparation are valuable in treating staphylococcal colonization.[2][13][24]

In the case of staphylococcal colonization of the nares, this should also be eradicated.

Primary options

mupirocin topical: children and adults: (2%) apply to the affected area(s) four times daily for 7-14 days

2nd line – oral fluconazole

Back
ACUTE
|
infectious etiology
|
no concurrent use of warfarin, phenytoin, or sulfonylureas
2nd line – 

oral fluconazole

Second-line therapies include fluconazole and amphotericin-B lozenges.[25] However, the lozenges are not currently available in the US.

Primary options

fluconazole: children: 6 mg/kg orally as a single dose on day 1, followed by 3 mg/kg/day for 13 days; adults: 200 mg orally as a single dose on day 1, followed by 100 mg once daily for 13 days

Consider – topical antibacterial

Back
ACUTE
|
infectious etiology
|
no concurrent use of warfarin, phenytoin, or sulfonylureas
Consider – 

topical antibacterial

Treatment recommended for SOME patients in selected patient group

Topical mupirocin or a polymyxin-containing preparation are valuable in treating staphylococcal colonization.[2][13][24]

In the case of staphylococcal colonization of the nares, this should also be eradicated.

Primary options

mupirocin topical: children and adults: (2%) apply to the affected area(s) four times daily for 7-14 days

1st line – topical nystatin

Back
ACUTE
|
infectious etiology
|
concurrent use of warfarin, phenytoin, or sulfonylureas
1st line – 

topical nystatin

Miconazole is absorbed systemically and may potentiate the action of warfarin, phenytoin, and sulfonylureas; thus, topical nystatin or amphotericin-B are first-line therapies in patients taking these drugs.[13][23][24] However, topical amphotericin-B products are not currently available in the US.

Primary options

nystatin topical: children and adults: (100,000 units/g) apply to the affected area(s) twice daily until healing is complete

Consider – topical antibacterial

Back
ACUTE
|
infectious etiology
|
concurrent use of warfarin, phenytoin, or sulfonylureas
Consider – 

topical antibacterial

Treatment recommended for SOME patients in selected patient group

Topical mupirocin or a polymyxin-containing preparation are valuable in treating staphylococcal colonization.[2][13][24]

In the case of staphylococcal colonization of the nares, this should also be eradicated.

Primary options

mupirocin topical: children and adults: (2%) apply to the affected area(s) four times daily for 7-14 days

noninfectious etiology

1st line – supportive management

Back
ACUTE
|
noninfectious etiology
1st line – 

supportive management

Supportive care includes management of dentures, which should be removed from the mouth at night and cleansed well before reinsertion in the morning. They can be stored in hypochlorite or chlorhexidine. Improvement in denture fit or new dentures may be necessary.[22]

For all patients, nutritional deficiencies are to be identified and corrected.[2]

Depending on patch test results, avoidance of the specific identified allergen is recommended.

ONGOING

recalcitrant disease

1st line – oral fluconazole

Back
ONGOING
|
recalcitrant disease
1st line – 

oral fluconazole

First-line therapy includes systemic antifungal therapy with fluconazole.[25]

Amphotericin-B lozenges are often used with fluconazole; however, they are not currently available in the US.

Primary options

fluconazole: children: 6 mg/kg orally as a single dose on day 1, followed by 3 mg/kg/day for 13 days; adults: 200 mg orally as a single dose on day 1, followed by 100 mg once daily for 13 days

2nd line – dermal fillers

Back
ONGOING
|
recalcitrant disease
2nd line – 

dermal fillers

Options include the use of dermal fillers in the commissures.[26][27]

3rd line – prosthodontic evaluation and construction

Back
ONGOING
|
recalcitrant disease
3rd line – 

prosthodontic evaluation and construction

Prosthodontic evaluation and construction is an option for older patients who suffer from chronic drooling and angular cheilitis.[28]

For older and disabled patients, a cannula may be incorporated into the denture prosthesis to channel the saliva toward the oropharyngeal area.[28]

back arrow

Choose a patient group to see our recommendations

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

Use of this content is subject to our disclaimer