Oral Thrush in Adults

Oral thrush is candidal infection of the oral mucosa, most often by Candida albicans. It presents as pseudomembranous plaques, erythematous patches or angular cheilitis.

• Risk factors are denture use, inhaled or systemic corticosteroids, broad spectrum antibiotics, diabetes, HIV, chemotherapy, xerostomia and smoking.
• In HIV, oral thrush indicates advanced immunosuppression and may spread to the oesophagus.
• Oesophageal candidiasis causes painful swallowing.

Creamy white plaques that wipe off leaving a red base, burning, taste change, soreness on eating, cracked mouth corners, and a smooth red tongue or palate.

• Dysphagia or odynophagia suggests oesophageal disease.
• Differential diagnosis: leukoplakia, lichen planus, hairy leukoplakia, geographic tongue, chemical burn, aphthous ulcers, herpetic stomatitis, pemphigus, oral cancer, syphilis.
• Complications: oesophageal candidiasis, dissemination in neutropenia, weight loss and poor intake, chronic hyperplastic candidiasis.

Clinical diagnosis, with confirmation if refractory.

• KOH preparation or Gram stain of a swab; fungal culture and susceptibility if resistant.
• Blood glucose, HIV test and CD4 count if not known.
• Upper endoscopy if dysphagia persists despite treatment.

Topical therapy for mild disease; fluconazole for moderate to severe disease.

• Supportive: oral hygiene with soft brush, rinse the mouth after inhaled steroids and use a spacer, remove dentures at night and soak them in chlorhexidine 0.2 percent, stop smoking, glucose control, adequate fluids.
• Pharmacological: nystatin suspension 100,000 units/mL, 4 to 6 mL four times daily, held in the mouth and swallowed, for 7 to 14 days; miconazole oral gel 2 percent, 2.5 mL four times daily; clotrimazole lozenge 10 mg five times daily for 7 to 14 days. Moderate or severe: fluconazole 100 to 200 mg daily for 7 to 14 days. Oesophageal: fluconazole 200 to 400 mg daily for 14 to 21 days. Refractory: itraconazole solution 200 mg daily, or voriconazole 200 mg twice daily. Check interactions of azoles with warfarin, phenytoin and antiretroviral drugs.
• Procedures: endoscopy for oesophageal disease not responding to treatment.
• Special groups: pregnancy, topical clotrimazole or nystatin, avoid fluconazole; HIV, start antiretroviral therapy and give fluconazole 200 mg daily for 14 days; denture wearers, treat the denture; infants, nystatin drops.
• Red flags: dysphagia, weight loss, no response in 2 weeks, white plaques that do not wipe off, recurrent infection without cause, neutropenia.
• Follow-up: review at 2 weeks; evaluate for diabetes and HIV if recurrent.