Thrush

Aka: Thrush, Oral Candidiasis, Candida Albicans Pharyngitis, Oral Erythematous Candidiasis, Pseudomembranous Candidiasis, Atrophic Candidiasis, Hyperplastic Candidiasis, Neonatal Thrush

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II. Epidemiology

  1. Candida colonizes 30-60% of healthy mouths
    1. Opportunistic infection occurs in the immunosuppressed or immature Immune Systems
  2. Common in infants, especially Breast fed
    1. Rare in first week of life
    2. Peaks at 4 weeks of age

III. Risk Factors: Adults with Thrush (Immunodeficiency)

  1. Human Immunodeficiency Virus
  2. Corticosteroid exposure
    1. Prolonged systemic steroids
    2. Inhaled Corticosteroids
  3. Dentures
  4. Xerostomia
  5. Leukemia
  6. Malnutrition
  7. Radiation Therapy
  8. Systemic Chemotherapy
  9. Broad-spectrum Antibiotics
  10. Diabetes Mellitus

IV. Risk Factors: Children with chronic Thrush

  1. Hypoparathyroidism
  2. Addison's Disease
  3. Hypothyroidism
  4. Diabetes Mellitus

V. Risk Factors: Systemic Candidiasis

  1. Acquired ImmunodeficiencyVirus
  2. Diabetes Mellitus
  3. Immunosuppressive Therapy
  4. Malignancy
  5. Neutropenia
  6. Organ Transplantation
  7. Prematurity

VI. Types

  1. Pseudomembranous Candidiasis (most common, Neonatal Thrush, typical erythematous Candidiasis)
    1. White Plaque adherent to erythematous mucosa over Palate, Buccal mucosa, Tongue
    2. Adherent, but does rub off with scraping to reveal an underlying erythematous mucosa
  2. Atrophic Candidiasis
    1. Generalized Oral Mucosa erythema
  3. Denture Stomatitis
    1. Localized form of Atrophic Candidiasis, limited to region of denture contact
    2. Dental prosthesis interferes with Saliva contact with mucosa (loss of antimicrobial protection)
    3. Remove dentures overnight and soak in 0.1% sodium Hypochlorite or 4% Chlorhexidine
  4. Hyperplastic Candidiasis (less common)
    1. See Angular Cheilitis
    2. Hyperplastic Plaques on lateral Tongue or oral commisures (angle between upper and lower lip)
    3. Hyperplastic Plaques are difficult to wipe off
    4. Differentiate from Leukoplakia (biopsy lesions that do not resolve)
  5. Median Rhomboid Glossitis
    1. Dorsal Tongue erythema and depillation

VII. Symptoms

  1. Pharyngitis
    1. Oral burning Sensation
    2. Mild Pharyngitis compared with Streptococcal Pharyngitis
  2. Dysphagia
  3. Nausea
  4. Vomiting
  5. Dysgeusia (Metallic Taste)

VIII. Signs: General

  1. See types above for specific findings
  2. White, curd-like or cottony patches or Plaques
  3. Alternative presentations
    1. Median Rhomboid Glossitis (Tongue)
    2. Perleche (Angular Cheilitis)

IX. Differential Diagnosis

  1. See Pharyngitis Causes
  2. Other opportunistic fungus (e.g. Aspergillus) in Immunocompromised patients
  3. Leukoplakia
    1. Does not rub off with scraping
  4. Esophageal Candidiasis (Immunocompromised patients)
    1. Consider if Dysphagia or odynophagia

X. Management: First-Line Agents

  1. Nystatin
    1. Adults
      1. Pastilles: 200,000 unit lozenge four times daily for 14 days
      2. Swish and swallow: 500,000 units (5 ml) four times daily for 14 days
      3. Tablets: Two 500,000 unit tablets three times daily for 14 days
    2. Child
      1. Swish and swallow 500,000 units (5 ml) orally four times daily for 14 days
    3. Infant
      1. Suspension (100,000 u/ml): Swab 1 ml on each cheek four times daily for 14 days
      2. Decrease dose in Preterm or low-birth weight infants to 0.5 ml/cheek
      3. Avoid feeding infant for 5 to 10 minutes after dose
  2. Clotrimazole troche (Mycelex)
    1. Adults
      1. Troche: 10 mg five times daily for 14 days
      2. Vaginal Suppository: 100 mg qd to bid for 14 days
    2. Adverse Effects
      1. May raise Liver Function Tests
      2. Gastrointestinal Side effects
  3. Fluconazole
    1. Adults
      1. Initial: 200 mg orally for 1 dose
      2. Later: 100 mg daily for 5-7 days (up to 10-14 days)
      3. Suppression in Immunocompromised patients: Fluconazole 100 mg orally three times weekly
    2. Children
      1. Protocol 1: 5 mg/kg orally daily for 5 days
      2. Protocol 2: 6-12 mg/kg day 1, then 3-6 mg/kg for 10 days
        1. Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]

XI. Management: Alternative Agents

  1. Itraconazole
    1. Indicated in Immunocompromised adults with concurrent esophageal involvement (also covers Aspergillus)
    2. Adults: 200 mg orally daily for 10-14 days
  2. Amphotericin B Oral Suspension
    1. Adults with HIV: 3-5 ml PO qid
    2. Indicated for refractory oropharyngeal Candidiasis
  3. Other Antifungal agents
    1. Posaconazole
    2. Voriconazole
    3. Capsofungin, Micafungin or Anidulafungin
  4. Miconazole gel
    1. Not currently available in U.S.
  5. Other treatments used historically
    1. Gentian Violet?
    2. Homemade Recipe
      1. 2 drops of dish soap
      2. 1/4 tsp Baking Soda
      3. Glass of warm water
      4. Apply to roof of mouth w/ cotton applicator qid

XII. Prevention

  1. See types above for specific measures
  2. In HIV patients, Antiretroviral therapy is typically used to prevent recurrence

XIII. Reference

  1. Anderson (2019) Crit Dec Emerg Med 33(9): 3-10
  2. Hoppe (1997) Pediatr Infect Dis J 16:885-94 [PubMed]
  3. Pappas (2016) Clin Infect Dis 62(4):409-17 +PMID:26810419 [PubMed]
  4. Randall (2022) Am Fam Physician 105(4): 369-76 [PubMed]

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