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Regarding oral antifungal therapy, Stengel et al. compared fluconazole, 150 mg once weekly, with ketoconazole, 200 mg daily, in an RCT of 158 patients who had different forms of dermatophytosis, including a few with cutaneous candidiasis. Cure rates were similar in the patients with cutaneous candidiasis (fluconazole three of three, ketoconazole two of three).21

In a similar design, fluconazole, 150 mg once weekly, was compared with 50 mg daily. The results for cutaneous candidiasis at one month were 100% (9/9) and 92% respectively. The overall intention-to-treat analysis for all kinds of treated fungal infections showed no significant differences for the two regimens.22

What is the best treatment for oropharyngeal candidosis?

A parallel, double-blind RCT evaluated the effectiveness of nystatin pastilles (200 000 and 400 000 units) with placebo. Twenty-four subjects were selected on the basis of clinical signs of denture stomatitis and culture isolation of Candida. Both dosages were found to be effective after 7 and 14 days' treatment, significantly reducing or eliminating Candida during active therapy, and 10 days after cessation of treatment. Data from the 10-day follow up, however, demonstrated reinfection with the organism in most subjects.23

Another RCT evaluated the effectiveness of an antifungal denture soaking solution (nystatin, 10 000 lU/ml) used as an adjunct to a nystatin vaginal lozenge (100 000 lU/g), three times daily for 7 days, compared with tap water in a group of older chronically ill adults. Although the clinical signs and symptoms of oral candidiasis were resolved in all subjects, the presence of Candida hyphae was detected in about 80% of tissue and/or dentures. When compared with tap water, the use of an antifungal denture soaking solution produced no detectable difference in the presence of C. albicans hyphae over a 3-month period, but it did reduce the rate of recurrence of clinical signs and symptoms.24

A multicentre RCT by Murray et al compared the efficacy and safety of oral itraconazole solution, 200 mg once daily, and clotrimazole troches, 10 mg five times daily, in 162 (142 evaluable) immunocompromised patients, mostly with AIDS. At the end of treatment significantly more patients in the clotrimazole group had negative cultures and a clinical cure than in the itraconazole group (53% versus 30%). Both drugs were well tolerated.25

In another RCT a total of 167 HIV-infected patients with oropharyngeal candidiasis received 14 days' therapy with either fluconazole suspension, 100 mg once daily, or liquid nystatin, 500 000 units four times daily. At day 14, 87% of the fluconazole-treated patients were clinically cured, compared with 52% in the nystatin-treated group (P<0-001). Fluconazole eradicated Candida organisms from the oral flora in 60%, compared with a 6% eradication rate with nystatin (P<0-001). The fluconazole group had fewer relapses noted on day 28 (18% versus 44% in the nystatin group; P<0-001) but this difference in relapse rates was no longer evident by day 42.26

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