Candidiasis of the oral mucosa B37.0

Infestation mainly of the tongue, also buccal mucosa, soft and hard palate, with single or confluent white to gray-white plaques, usually easy to wipe off; sometimes tongue burning.

According to Mayser (2018) several clinical manifestations can be distinguished:

• Acute pseudomembranous candidosis (oral thrush)
• Acute erythematous candidosis
• Acute atrophic candidiasis (dental carrier stomatitis)
• Chronic hyperplastic candidiasis (Candida leukoplakia)
• Perlèche (Angulus infectiosus)

Frequent occurrence, especially in infants, in patients with chronic bronchial asthma who are treated with long-term inhaled glucocorticoids, with immunosuppression, diabetes mellitus or in elderly people with poorly fitting or unkempt dentures. Oral candidiasis is the most common opportunistic disease in HIV-infected persons. Erosive diseases of the oral mucosa such as lichen planus erosivus, pemphigus vulgaris and others are also predisposing factors.

Acute pseudomembranous candidiasis (oral thrush)

Acute pseudomembranous candidiasis is the clinical manifestation of oral candidiasis, which is generally referred to as classic oral thrush. It occurs mainly in newborns and in immunodeficiency.

Here, low-symptom, whitish deposits are found on flat enanthema, initially in spots, later in small areas or confluent large areas. The deposits can be easily scraped off with a wooden spatula. After scraping, an underlying, deep red, slightly bleeding mucous membrane is found. Subjectively, discomfort such as taste disturbances and/or a furry feeling are expressed. This form of oral candidiasis is often associated with candidiasis of the pharynx, oesophagus or tongue.

Acute erythematous candidiasis

Clinically, there is a swollen, shiny, bright red oral mucosa with streaked papillae. The surface of the tongue is usually affected. Acute erythematous candidiasis usually develops from a pre-existing acute pseudomembranous candidiasis. It mainly occurs in immunodeficiencies or after prolonged antibiotic therapy.

Chronic atrophic candidiasis

This form of oral candidiasis usually occurs in denture wearers (denture stomatitis) at the contact points of the denture. The lesional mucosa is bright red and atrophic and shiny. The changes are localized to the hard palate and the gingival mucosa of the lower and upper jaw in accordance with the prosthesis contact points. The subjective sensation is only slightly impaired.

Candida leukoplakia

It is still unclear whether this clinical symptomatology should be described as Candida leukoplakia or as hyperplastic candidiasis. It is also unclear whether the Candida infection is the cause of the leukoplakia or whether it is a superinfection of a pre-existing mucosal change.

Clinically, this clinical picture is characterized by a (cobblestone-like) leukoplakia (in contrast to classic oral thrush, no easily strippable deposits). The leukoplakic changes are surrounded by an erythema border. It is important to differentiate (or exclude) a premalignant leukoplakia.

Non-absorbable antimycotics such as amphotericin B or nystatin in liquid form (e.g. Ampho-Moronal suspension or lozenges, Candio-Hermal suspension, Nystatin Lederle Trp.) for at least 10 days. Gargling with a 1:50 diluted Amphotericin B solution twice a day has proved effective.

In case of severe infestation or involvement of the esophagus (thrush esophagitis), systemic therapy with fluconazole (e.g. Diflucan) 200 mg/day for 10-14 days. Resistance is known, after therapy control with throat rinsing water, combination therapy with amphotericin B or liposomal amphotericin B (AmBisome) and flucytosine (e.g. Ancotil) if necessary. See below Candida sepsis.

Alternative: Posaconazole - day 1: 1x 200 mg p.o.; then 100 mg p.o. for 13 days.

Alternatively: in therapy-resistant cases, amphotericin B 0.3 mg/kg bw/day i.v. for 5-10 days.

Secondary prophylaxis for recurrent oral thrush (possibly with thrush esophagitis): Fluconazole 50 mg/day p.o. or 3x/week 100 mg/day p.o. Alternatively: Posaconazole - 3x 200 mg/day.

In immunosuppressed patients: fluconazole, initially 200 mg p.o., then 100 mg/day for 5-10 days. If there is no response, double the dose.

1. Fukushima C et al (2003) Oral candidiasis associated with inhaled corticosteroid use: comparison of flucasone and beclomathasone. Ann Allergy Asthma Immunol 90: 646-651

2. Mayer P (2018) Mycoses. In: Braun-Falco`s Dermatology, Venerology Allergology G. Plewig et al. (Hrsg) Springer Verlag S 280-281