Oral thrush (and angular cheilitis)

Gastrointestinal Conditions

Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.

Clinical features

Pseudomembranous oral candidiasis presents with patches of curd-like white on the cheeks, gums, and palate. The patches are can be removed easily revealing a red base that is not usually painful

Acute erythematous oral candidiasis is associated with soreness and erythema and often follows on from oral thrush or after treatment with oral antibacterials

Angular cheilitis presents with redness, fissuring, and soreness at the angle of the mouth, and may be caused by bacterial infection (such as Staphylococcus aureus and beta-haemolytic streptococci) as well as yeast (Candida) species

Oral thrush

Angular cheilitis

Those in whom OTC product is not suitable (for example, due to age, existing medical condition or medicines, such as warfarin)

Patients with diabetes (could be linked to hyperglycaemia requiring a review of diabetic control and management)

Immunocompromised patients (infection could be more severe)

NB: unexplained oral candidiasis is an HIV indicator condition (as per the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020)

Suspected leukoplakia (a white patch or plaque on the mucosa that cannot be rubbed off) as it may be pre-malignant

Suspected erosive lichen planus (tender erythema and painful ulcers surrounded by white, radiating striae) as it may require biopsy to eliminate sinister causes

Suspected oral cancer (lump/thickening of soft tissue, feeling that something is caught in the throat, difficulty chewing or swallowing, ear pain, difficulty moving jaw/tongue, hoarseness, numbness)

Hairy tongue (could be due to poor oral hygiene, overuse of mouthwashes or certain medicines)

While it can be a self-limiting condition, it makes sense to initiate an antifungal product as soon as possible, particularly if the patient has associated pain, discomfort and it is interfering with eating and drinking

The OTC treatment for oral candidiasis should be continued for around a week after the symptoms have disappeared

Non-pharmacological advice

If the person wears dentures, advise about hygiene measures and how to prevent recurrence

If the oral candidiasis is linked to inhaled corticosteroids, consider ways to minimise the risk such as using a spacer device or rinsing the mouth with water after using the inhaler

Pharmacological advice

OTC miconazole for oral candidiasis

Infants aged 4 to 24 months (contraindicated under 4 months, and under 5 to 6 months in pre-term infants or those with slow neuromuscular development): 1.25 ml four times daily after meals. Each dose should be divided into smaller portions and the gel should be applied to the affected area(s) with a clean finger. The gel should not be applied to the back of the throat due to possible choking. The gel should not be swallowed immediately, but kept in the mouth as long as possible

Adults and children 2 years and over: 2.5 ml four times daily after meals. The gel should not be swallowed immediately, but kept in the mouth as long as possible

The treatment should be continued for around a week after the symptoms have disappeared

Consider how useful a 15g OTC product would be given the length of the course of treatment and that an adult uses 10mL (approx. 10g) per day

Pregnancy: refer to doctor. If breast-feeding, suggest mother speaks to doctor. She may need a suitable antifungal cream for the nipple area to prevent cross-contamination from infant with oral thrush to mother

Daktarin SF oral gel SmPC states: serious skin reactions (such as toxic epidermal necrolysis and Stevens-Johnson syndrome) have been reported in patients receiving Daktarin Sugar Free 2% Oral Gel. It is recommended that patients be informed about the signs of serious skin reactions, and that use of Daktarin be discontinued at the first appearance of skin rash

Angular chelitis

BNF states that while the underlying cause is being identified and treated, it is often helpful to apply miconazole cream (check OTC licence) or fusidic acid ointment (via a prescription since POM); if the angular cheilitis is unresponsive to treatment, hydrocortisone with miconazole cream or ointment (will be via prescription, since OTC topical hydrocortisone products are not suitable for use on the face) can be used