How should I approach the management of candidiasis in immunocompromised patients?

In managing candidiasis in immunocompromised patients, the approach should prioritise systemic antifungal therapy due to the increased risk of extensive or severe infection and potential for invasive disease. High-dose oral fluconazole is generally preferred as first-line treatment for oral candidiasis in this population, given its broad antifungal spectrum and systemic absorption, which is advantageous for widespread infection ¹. For patients with mild, localized infection who are on immunosuppressants such as corticosteroids or DMARDs, topical treatments like miconazole oral gel may be considered initially, but treatment duration should extend at least 7 days beyond symptom resolution to ensure eradication ².

Specialist advice should be sought before initiating antifungal therapy in patients receiving drugs with significant interactions, such as ciclosporin or tacrolimus, or those undergoing chemotherapy, due to complex drug interactions and the risk of neutropenia ². In cases of persistent or severe candidiasis, or if there is suspicion of invasive disease (e.g., oesophageal candidiasis), referral to secondary care is warranted for further management ².

Adjunctive measures include managing predisposing local and systemic risk factors, such as improving dental hygiene, smoking cessation, and optimising control of underlying conditions like diabetes ¹,². For patients wearing dentures, cleaning with chlorhexidine and removing dentures for at least 6 hours daily can reduce Candida colonisation and promote mucosal healing ¹,².

Recent literature highlights the evolving epidemiology of invasive fungal infections in immunocompromised hosts and the emergence of new antifungal agents, underscoring the importance of specialist involvement in complex cases to tailor therapy and manage resistance patterns (Giannella et al., 2025; Cornely et al., 2025). Additionally, emerging concerns about Candida auris infections in this population necessitate heightened diagnostic vigilance and may require alternative antifungal strategies (Posteraro et al., 2025).

In summary, the management of candidiasis in immunocompromised patients involves systemic antifungal therapy with fluconazole as first-line, careful consideration of drug interactions, adjunctive local care, and specialist referral for severe or persistent cases, integrating evolving evidence on antifungal resistance and emerging pathogens.