Mucosal Candidiasis Treatment & Management

Updated: Aug 28, 2017
  • Author: Surbhi Gupta; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

Medical therapies

Medications used to treat candidiasis can be topical or systemic agents, and, in most cases, therapy is initiated with topical medications. However, severe disease, esophageal involvement, or inadequate response to topical medications may warrant systemic therapy. The following treatment recommendations are adapted from the Clinical Practice Guideline for the Management of Candidiasis from the Infectious Diseases Society of America (IDSA). [14]

Oropharyngeal treatment is as follows:

  • Mild: Nystatin suspension four times a day for 1-2 weeks, or 10 mg clotrimazole troche five times a day for 1-2 weeks
  • Moderate to severe: 100-200 mg oral daily fluconazole for 1-2 weeks
  • Refractory to fluconazole: 200 mg itraconazole solution once a day for up to 4 weeks
  • HIV patients: Antiretroviral therapy strongly recommended
  • Dentures: Disinfect dentures along with antifungal therapy
  • Chlorhexidine oral rinses may be of some benefit in the control of oral candidiasis, as may some essential oils [15]

Esophageal treatment is as follows:

  • Requires systemic therapy; empiric treatment is acceptable prior to endoscopy
  • Initial therapy: 200-400 mg oral daily fluconazole for 2-3 weeks
  • Unable to tolerate oral medication: 400 mg daily intravenous fluconazole, or an echinocandin (eg, 150 mg daily intravenous micafungin), then deescalate when tolerable to 200-400 mg oral daily fluconazole
  • Refractory to fluconazole: 200 mg itraconazole solution once a day, or 200 mg oral or intravenous voriconazole twice a day for 2-3 weeks
  • Recurrent: Long-term therapy with 100-200 mg oral fluconazole three times per week

Vulvovaginitis treatment is as follows:

  • Uncomplicated: Any topical azole or a single dose of 150 mg oral fluconazole
  • Severe or immunosuppressed: 2-3 doses of 150 mg oral fluconazole every 72 hours
  • Candida glabrata infection, unresponsive to azoles: 600 mg intravaginal boric acid capsule nightly for 10-14 days, [16] or intravaginal nystatin [17]
  • Recurrent: Induction therapy with 2 weeks of a topical agent or oral fluconazole, followed by weekly 150 mg oral fluconazole for 6 months

Balanitis treatment is as follows:

  • Mild: Topical imidazole twice a day for 1-2 weeks
  • Severe or recurrent: 50-100 mg oral fluconazole once a day for 2 weeks

Chronic mucocutaneous candidiasis treatment is as follows:

  • Patients with associated endocrine abnormalities, such as those involving the parathyroid, should have electrolytes monitored and corrected as necessary
  • Initial: 400-800 mg oral fluconazole once a day for 4-6 months
  • Maintenance: 200 mg oral fluconazole once a day

Resistance of fungi to azoles is rare, but some Candida species, such as C glabrata and C krusei, are innately less susceptible to azoles. C albicans can acquire azole resistance. [18]

Boric acid

This can be compounded by a pharmacist or purchased online. Patients may also make their own capsules using boric acid powder and gelatin capsules. They should fill the narrow half of the capsule, and then cap it with the wider half. To prevent recurrence, boric acid can be used twice a week. The mechanism by which topical boric acid is effective in vulvovaginitis due to Candida is not well understood, but one theory is that it may inhibit oxidative metabolism or impair virulence. Adverse effects can be mild, such as local irritation. Systemic adverse effects can also occur and can include fever, vomiting, and seizures. Patients should be warned that boric acid capsules can be fatal if swallowed, and they should not be used during pregnancy.

Treating underlying causes

Attention to the underlying cause helps avoid prolonged or repeated courses of treatment. If antibiotics or corticosteroids (oral or inhaled) are the underlying cause, reducing the dose or changing the treatment may help. Intermittent or prolonged topical antifungal treatment may be necessary when the underlying cause is unavoidable or incurable.

Denture plaque often contains Candida species. To prevent denture-induced stomatitis, denture cleansing that includes removal of candidal organisms is a necessary and important factor. Cleansers can be divided into groups according to their primary components: alkaline peroxides, alkaline hypochlorites, acids, disinfectants, and enzymes. Yeast lytic enzymes and proteolytic enzymes are the most effective. Denture soak solutions with benzoic acid eradicate C albicans from the denture surface by being taken up by the acrylic resin and eliminating the organism from the internal surface of the prosthesis. Oral rinses containing 0.12% chlorhexidine gluconate eliminate C albicans on the acrylic resin surface of the denture, and they reduce palatal inflammation. Protease-containing denture soaks (alkalize protease) remove denture plaque, especially when combined with brushing.

Xerostomia causing candidiasis can benefit from keeping the mouth moist through hydration, ice chips, or lozenges. If the dry mouth is the anticholinergic adverse effect of another medication, consider switching to another medication or changing the dosage. Treatment with cholinergic agents may also be considered.

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Prevention

Patients should be counseled about smoking, and they should be warned about the risk of developing mucosal candidiasis after taking medications that impair salivation, antibiotics, corticosteroids, and other immunosuppressants.

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