There can be variation in the licensing of
different medicines containing the same drug.
Dispersible tablet
CAUTIONARY AND ADVISORY LABELS 6, 9, 11, 13
▶Vibramycin-D (Pfizer Ltd)
Doxycycline (as Doxycycline monohydrate) 100 mg Vibramycin-D
100mg dispersible tablets sugar-free | 8 tablet P £4.91 DT = £4.91
Oropharyngeal fungal
infections
Oropharyngeal fungal infections
Overview
Fungal infections of the mouth are usually caused by
Candida spp. (candidiasis or candidosis). Different types of
oropharyngeal candidiasis are managed as follows:
Thrush
Acute pseudomembranous candidiasis (thrush), is usually an
acute infection but it may persist for months in patients
receiving inhaled corticosteroids, cytotoxics or broad-
spectrum antibacterials. Thrush also occurs in patients with
serious systemic disease associated with reduced immunity
such as leukaemia, other malignancies, and HIV infection.
Any predisposing condition should be managed
appropriately. When thrush is associated with corticosteroid
inhalers, rinsing the mouth with water (or cleaning a child’s
teeth) immediately after using the inhaler may avoid the
problem. Treatment with nystatin p. 1284 or miconazole
below may be needed. Fluconazole p. 630 is effective for
unresponsive infections or if a topical antifungal drug
cannot be used or if the patient has dry mouth. Topical
therapy may not be adequate in immunocompromised
patients and an oral triazole antifungal is preferred.
Acute erythematous candidiasis
Acute erythematous (atrophic) candidiasis is a relatively
uncommon condition associated with corticosteroid and
broad-spectrum antibacterial use and with HIV disease. It is
usually treated with fluconazole.
Denture stomatitis
Patients with denture stomatitis (chronic atrophic
candidiasis), should cleanse their dentures thoroughly and
leave them out as often as possible during the treatment
period. To prevent recurrence of the problem, dentures
should not normally be worn at night. New dentures may be
required if these measures fail despite good compliance.
Miconazole oral gel can be applied to the fitting surface of
the denture before insertion (for short periods only).
Denture stomatitis is not always associated with candidiasis
and other factors such as mechanical or chemical irritation,
bacterial infection, or rarely allergy to the dental base
material, may be the cause.
Chronic hyperplastic candidiasis
Chronic hyperplastic candidiasis (candidal leucoplakia)
carries an increased risk of malignancy; biopsy is essential—
this type of candidiasis may be associated with varying
degrees of dysplasia, with oral cancer present in a high
proportion of cases. Chronic hyperplastic candidiasis is
treated with a systemic antifungal such as fluconazole to
eliminate candidal overlay. Patients should avoid the use of
tobacco.
Angular cheilitis
Angular cheilitis (angular stomatitis) is characterised by
soreness, erythema and fissuring at the angles of the mouth.
It is commonly associated with denture stomatitis but may
represent a nutritional deficiency or it may be related to
orofacial granulomatosis or HIV infection. Both yeasts
(Candida spp.) and bacteria (Staphylococcus aureus and beta-
haemolytic streptococci) are commonly involved as
interacting, infective factors. A reduction in facial height
related to ageing and tooth loss with maceration in the deep
occlusive folds that may subsequently arise, predisposes to
such infection. While the underlying cause is being
identified and treated, it is often helpful to apply miconazole
cream or fusidic acid ointment p. 604; if the angular cheilitis
is unresponsive to treatment, hydrocortisone with
miconazole cream p. 1318 or ointment can be used.
Immunocompromised patients
See advice on prevention of fungal infections in
Immunocompromised patients under Antifungals, systemic
use p. 626.
Drugs used in oropharyngeal candidiasis
Nystatin is not absorbed from the gastro-intestinal tract and
is applied locally (as a suspension) to the mouth for treating
local fungal infections. Miconazole is applied locally (as an
oral gel) in the mouth but it is absorbed to the extent that
potential interactions need to be considered. Miconazole
also has some activity against Gram-positive bacteria
including streptococci and staphylococci. Fluconazole is
given by mouth for infections that do not respond to topical
therapy or when topical therapy cannot be used. It is reliably
absorbed and effective. Itraconazole p. 632 can be used for
Ear, nose and oropharynx
fluconazole-resistant infections.
If candidal infection fails to respond to 1 to 2 weeks of
treatment with antifungal drugs the patient should be sent
for investigation to eliminate the possibility of underlying
disease. Persistent infection may also be caused by
reinfection from the genito-urinary or gastro-intestinal
tract. Infection can be eliminated from these sources by
appropriate anticandidal therapy; the patient’s partner may
also require treatment to prevent reinfection.
Antiseptic mouthwashes are used in the prevention of oral
candidiasis in immunocompromised patients and in the
treatment of denture stomatitis.
ANTIFUNGALS › IMIDAZOLE ANTIFUNGALS
PDF pages 1304, 1305
