Candidiasis of the oral mucosaB37.0

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)

Increased incidence especially in infants, in patients with chronic bronchial asthma who are permanently treated with inhaled glucocorticoids, in immunosuppression, diabetes mellitus or in old people with poorly fitting and well maintained dentures. Oral candidiasis is the most common opportunistic disease in HIV-infected persons. Predisposing are also erosive diseases of the oral mucosa such as lichen planus erosivus, pemphigus vulgaris and others.

Acute pseudomembranous candidosis (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.

In this case, whitish deposits are found on flat enanthema, low in symptoms, initially in stippling, later on small areas or confluent large areas. The coatings can be easily removed with a wooden spatula. After stripping off the coatings, there is an underlying, deep red, slightly bleeding mucous membrane. Subjectively, discomfort such as impaired taste and/or furry feeling is expressed. This form of oral candidiasis is often associated with candidiasis of the pharynx, oesophagus or tongue.

Acute erythematous candidiasis

Clinically a swollen, shiny, bright red oral mucosa with elapsed papillae is found. The tongue surface is usually affected. Acute erythematous candidosis usually develops from pre-existing acute pseudomembranous candidosis. It occurs mainly with immunodeficiencies or after long-term antibiotic therapy.

Chronic atrophic candidiasis

This form of oral candidiasis usually occurs with prosthesis wearers (dentition carrier stomatitis) under the contact points of the denture. The lesional mucosa is bright red, atrophically shiny. The changes in the hard palate as well as in the gingival mucosa of the upper and lower jaw correspond to the prosthesis contact points. The subjective sensation is only slightly disturbed.

Candida leukoplakia

Until today it is still unclear whether this clinical symptomatology can 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-existent mucosal change.

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

In case of severe affection or involvement of the esophagus (thrush esophagitis) systemic therapy with Fluconazole (e.g. Diflucan) 200 mg/day for 10-14 days. Resistances are known, after therapy control with pharyngeal rinsing water or combination therapy with Amphotericin B or liposomal Amphotericin B (AmBisome) and Flucytosin (e.g. Ancotil). S.u. Candida sepsis.

Alternative: Posaconazole day 1:1x200mg p.o.; afterwards 100mg p.o. for 13 days.

Alternative: In therapy-resistant cases Amphotericin B 0.3 mg/kg bw/day i.v. for 5-10 days.

Secondary prevention of recurrent oral thrush (possibly with oral esophagitis): Fluconazole 50 mg/day p.o. or 3 times/week 100 mg/day p.o. Alternatively: Posaconazole: 3x200mg/day.

In immunocompromised patients: Fluconazole initially 200 mg p.o., then 100 mg/day for 5-10 days. In case of non-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