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). [19]
Oropharyngeal treatment is as follows:
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Mild: Nystatin suspension four times a day for 1-2 weeks, or 10 mg clotrimazole troche five times a day for 1-2 weeks
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Moderate to severe: 100-200 mg oral daily fluconazole for 1-2 weeks
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Refractory to fluconazole: 200 mg itraconazole solution once a day for up to 4 weeks
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HIV patients: Antiretroviral therapy strongly recommended
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Dentures: Disinfect dentures along with antifungal therapy
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Chlorhexidine oral rinses may be of some benefit in the control of oral candidiasis, as may some essential oils [20]
Esophageal treatment is as follows:
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Requires systemic therapy; empiric treatment is acceptable prior to endoscopy
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Initial therapy: 200-400 mg oral daily fluconazole for 2-3 weeks
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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
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Refractory to fluconazole: 200 mg itraconazole solution once a day, or 200 mg oral or intravenous voriconazole twice a day for 2-3 weeks
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Recurrent: Long-term therapy with 100-200 mg oral fluconazole three times per week
Vulvovaginitis treatment is as follows:
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Uncomplicated: Any topical azole or a single dose of 150 mg oral fluconazole
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Severe or immunosuppressed: 2-3 doses of 150 mg oral fluconazole every 72 hours
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Candida glabrata infection, unresponsive to azoles: 600 mg intravaginal boric acid capsule nightly for 14 days, or 100,000 units intravaginal nystatin suppository daily for 14 days [19]
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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:
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Mild: Topical imidazole twice a day for 1-2 weeks
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Severe or recurrent: 50-100 mg oral fluconazole once a day for 2 weeks
Chronic mucocutaneous candidiasis treatment is as follows:
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Patients with associated endocrine abnormalities, such as those involving the parathyroid, should have electrolytes monitored and corrected as necessary
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Initial: 400-800 mg oral fluconazole once a day for 4-6 months
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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. [21] C lusitaniae is known for its resistance to amphoterocin B, and there is considerable concern regarding the emerging multidrug-resisant Candida species such as C. auris. [22]
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.
In the setting of mucosal erosions, appropriate treatment of the primary disorder (e.g. oral lichen planus, pemphigus vulgaris, etc.) prevents futher disruption of the oral mucosa, thereby limiting the development of secondary candidiasis. Patients with an active primary disease of the oral mucosa may benefit from adjunctive Candida-directed treament such as daily clotrimazole troches and/or a short course of oral fluconazole.
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Pseudomembranous candidiasis.
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Erythematous candidiasis in HIV/AIDS.
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Denture-related stomatitis; a common form of oral candidiasis. From Scully C, Flint SF, Bagan JV, Porter SR, Moos K. Atlas of Oral and Maxillofacial Diseases. 2010. Informa, London.
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Angular cheilitis; a common form of oral candidiasis, typically seen in patients with denture-related stomatitis, especially those in whom the denture needs adjustment. In others, it may be a sign of diabetes, nutritional deficiency, or immune defect.
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Multifocal candidiasis; lingual lesions.
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Chronic hyperplastic candidiasis; typically affects the tongue dorsum or the commissures of the lips; potentially malignant.
