Candidiasis (thrush, yeast infection) : How is candidiasis treated?

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Candidiasis (thrush, yeast infection)
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How is candidiasis treated?

Just as there are three different types of candidiasis, there are three somewhat different ways to treat the disease.

Oral Candidiasis
The most common method of treating oral thrush is to use a medicated liquid that is swished around the mouth and swallowed, or a lozenge that is sucked, dissolved in the mouth, and swallowed. The treatment recommended by the U.S. Centers for Disease Control and Prevention (CDC) as the most effective and best tolerated is:

Fluconazole (Diflucan tablets): Diflucan is a tablet that must be swallowed. Studies have demonstrated that it is just as effective as clotrimazole and nystatin, but is more convenient and better tolerated. The dose is typically 100mg a day for 7 to 14 days.

Alternative treatments include:

Clotrimazole (Mycelex trouches): These trouches, or lozenges, are used either four or five times a day for one or two weeks. Lozenges should be dissolved in the mouth slowly and should not be chewed or swallowed whole. Clotrimazole can cause stomach upset.
Nystatin (Mycostatin liquid or pastilles): Nystatin is available in liquid and pastille (lozenge) form. The liquid dose is 5 milliliters four times a day for one or two weeks; it should be swished around the mouth slowly, for as long as possible (i.e., a few minutes), and then swallowed. One or two pastilles are taken four or five times a day for 7 to 14 days; they should be dissolved in the mouth slowly and should not be chewed or swallowed whole.
Itraconazole (Sporanox liquid suspension): This medication is a liquid that must be swallowed. While it is as effective as the three medications listed above, it is not as well tolerated as fluconazole tablets.
Ketoconazole (Nizoral) or itraconazole (Sporanox) capsules: These capsules, which must be swallowed, are less effective that fluconazole. However, they are alternative options if the four medications listed above cannot be used.

Another possible treatment for oral candidiasis is gentian violet (Genapax). This is a dye made from coal tar and can be purchased from some pharmacies, health food stores, and other places where complementary/alternative therapies are sold. Gentian violet is very messy and can stain clothing. It should be handled with care. For oral thrush, one of the best ways to apply the dye is by using a cotton swab. Dip the swab in the dye and coat the Candida blotches in the mouth. It is best to avoid swallowing the drug, as it can cause stomach upset. Gentian violet can also stain the inside of the mouth, but this fades over time.

Vaginal Candidiasis
The most common method of treating vaginal yeast infections is to use a medicated cream or an insert (suppository) placed into the vagina. The most common treatments for vaginal candidiasis are available over-the-counter and can be purchased in many pharmacies. Many vaginal creams and suppositories can weaken condoms and diaphragms, which can increase the risk of pregnancy and HIV transmission.

Clotrimazole (Gyne-Lotrimin cream): Five grams of this cream are applied every day, using a special applicator, for 7 to 14 days.
Clotrimazole (Mycelex vaginal suppositories): Available in 100 mg and 500 mg strength suppositories and are available by prescription. The 100 mg suppositories are used every day for seven days. Alternatively, two 100 mg suppositories can be used every day for a total of three days. The 500 mg suppository is much more powerful than that 100 mg inserts and only needs to be inserted once.
Miconazole (Monistat vaginal cream): Five grams of this cream are applied every day, using a special applicator, for seven days.

Miconazole (Monistat vaginal suppositories): Available in 100 mg, 200 mg, and 500 mg strengths. The 100 mg and 200 mg suppositories are available over-the-counter and the 500 mg suppositories are available by prescription. The 100 mg suppositories are used once a day for seven days and the 200 mg suppositories are used once a day for three days. The 500 mg suppository only needs to be inserted once.

Terconazole (Terazol 3 and Terazol 7 creams): Terazol 3 contains a higher dose of terconazole than Terazol 7. Terazol 7 is applied every day, using a special applicator, for seven days. Terazol 3 is applied every day for three days.

Terconazole (Terazol 3 suppositories): These suppositories contain 80 mg terconazole and are inserted every day for three days.

Tioconazole (Vagistat ointment): This ointment contains 300 mg tioconazole and is inserted, using a special applicator, only once.

Butoconazole (Femstat cream): Five grams of this cream are applied every day, using a special applicator, for three days.

As with oral candidiasis, if vaginal yeast infections do not go away while using these creams of suppositories, or if the infection returns soon after treatment is stopped, more potent drugs such as nystatin (Mycostatin) liquid, itraconazole (Sporanox) liquid, or fluconazole (Diflucan) tablets can be prescribed by a doctor. Women who are pregnant should not use these oral drugs. They may harm the developing fetus.

Another possible treatment for vaginal yeast infections is gentian violet (Genapax). This is a dye made from coal tar and can be purchased from some pharmacies, health food stores, and other places where complementary/alternative therapies are sold. Genapax can be purchased in a tampon formulation; each tampon contains 5 mg of gentian violet. Gentian violet tampons can be messy and can stain clothing and undergarments. They should be handled and inserted with care. To treat vaginal yeast infections, gentian violet tampons are inserted once or twice a day for one to two weeks.

Esophageal Candidiasis
Because esophageal candidiasis is considered to be more severe, deeper in the body, and harder to treat than either oral thrush or vaginal yeast infections, more powerful drugs—using higher doses than those used to treat oral of vaginal candidiasis—are usually needed to treat it. These drugs can cause liver enzymes to increase. They can also interact with other medications, including protease inhibitors, non-nucleoside reverse transcriptase inhibitors, as well as certain antihistamines and sedatives. Be sure to check with your doctor about other drugs you are taking before taking these antifungal treatments.

Fluconazole (Diflucan): To treat esophageal candidiasis, an intravenous solution or 200 mg tablet of fluconazole is taken once a day for two or three weeks. Fluconasole is considered the first choice for treating esophogeal candidiasis, because blood levels of fluconazole fluctuate less than either itraconazole or ketoconazole.
Itraconazole (Sporanox): This drug is frequently used to treat esophageal candidiasis. Many doctors are now recommending that the liquid formula (itraconazole cyclodextrin solution) be used. If the itraconazole tablets are used, they are often taken with another drug, flucytosine (Ancobon), to increase effectiveness. For oral candidiasis, the dose of itraconazole used is usually 100 mg a day for one or two weeks. For esophageal candidiasis, the dose is usually 200 mg a day for two or three weeks. Itraconazole tablets should be taken with food; itraconazole liquid should be taken on an empty stomach.

Ketoconazole (Nizoral): 400 mg of Nizoral is taken every day for three or four weeks. This drug interacts with many antiretroviral drugs. It can increase indinavir (Crixivan), saquinavir (Invirase), and amprenavir (Agenerase) levels in the blood. Ritonavir (Norvir) can increase the amount of ketoconazole in the blood and, as a result, the daily ketoconazole dose should not exceed 200 mg.

Severe or Drug-Resistant Candidiasis

Sometimes, candidiasis can become resistant to the "azole" drugs (all of those listed above) or is so severe that it cannot be adequately treated using any of these treatments. As a result, a drug called amphotericin B is often used. It is usually administered in a hospital through an IV line. The two types of amphotericin B are standard amphotericin B (Fungizone) and liposomal amphotericin B (Abelcet, AmBisome, Amphotec).

Amphotericin B can cause serious side effects, including kidney damage, allergic reactions (e.g., fever, chills, altered blood pressure), bone marrow damage, nausea, vomiting, and headache. The risk of kidney damage is increased if amphotericin B is combined with cidofovir (Vistide) or ganciclovir (Cytovene), two drugs used to treat CMV, and pentamidine (NebuPent), a drug used to treat PCP. The risk of bone marrow damage is increased if amphotericin B is taken at the same time as AZT (Retrovir), flucytosine (Ancobon), or ganciclovir.

Generally speaking, the liposomal amphotericin B brands are less toxic than standard amphotericin B. However, standard amphotericin B is faster acting than any of the liposomal drugs and is usually the drug of choice when candidiasis or other fungal infections are severe and an immediate threat to life.

How should pregnant women be treated for candidiasis?

Because many of the drugs used to treat fungal infections can be toxic to the developing fetus, the CDC recommends that topical treatments—such as vaginal creams or suppositories for vaginal candidiasis—be used whenever possible.


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Last Revised: August 20, 2008

This content is written by the POZ and AIDSmeds editorial team. For more information, please visit our "About Us" page.

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