A variety of topical and systemically administered medications are now available to supplement the older polyene antifungal antibiotics nystatin and amphotericin B. An imidazole derivative (clotrimazole) is available for topical use. Systemic therapy includes the use of any one of these three: ketoconazole, itraconazole, and fluconazole. Fluconazole and amphotericin B may be used intravenously for the treatment of the resistant lesions of CMC and systemic candidiasis.
The majority of acute oral Candida infections respond rapidly to topical nystatin and will not recur, provided that the predisposing factors have also been eliminated. Seven to 21 days’ use of a nystatin rinse three to four times daily is usually adequate although some resistant cases may require a second course of treatment. Nystatin in cream form may also be applied directly to the denture or to the corners of the mouth. Patients for whom predisposing factors such as xerostomia and immunodeficiency cannot be eliminated may need either continuous or repeated treatment to prevent recurrences. Clotrimazole troches can also be used for treatment of oral lesions. The consumption of yogurt two to three times per week and improved oral hygiene can also help, especially if underlying predisposing factors cannot be eliminated.
Better patient compliance and more effective treatment of both acute and chronic candidiasis can usually be attained by a once-daily dose of 200 mg of ketoconazole, 100 mg of fluconazole,or itraconazole oral suspension (100 to 200 mg/d) for 2 weeks. When these medications are used for this short period, side effects such as increased liver enzymes, abdominal pain, and pruritus are rare. Vaginal candidiasis responds to ketoconazole and fluconazole even more rapidly than does oral candidiasis, and the likelihood of re-infection is reduced by the control of Candida at various sites. Fluconazole is more effective than ketoconazole, but its frequent use can lead to the development of resistance to the drug. Fluconazole therapy for oral candidiasis associated with HIV infection often results in the development of resistance to fluconazole. Itraconazole can be substituted for fluconazole in resistant patients, but fluconazole is still the mainstay of therapy for HIV-associated candidiasis.Fluconazole interacts with a number of other medications and must be prescribed with care for patients who are using anticoagulants, phenytoin, cyclosporine, and oral hypoglycemic agents. The simultaneous administration of ketoconazole (or the related antifungal itraconazole) and cisapride or antihistamines (terfenadine and astemizole) is associated occasionally with ventricular arrhythmias and other serious cardiovascular events.