A 16-year-old male comes to your office for a routine check-up. He was diagnosed with asthma six months ago and started on inhaled corticosteroids as well as an albuterol inhaler as needed. He reports a modest improvement in his symptoms using this regimen. He has no complaints currently. Physical examination reveals white plaques on his buccal mucosa that can be scraped off, leaving hyperemic spots. The lungs are clear on auscultation. Which of the following is the best initial therapy for the oral lesion?

Question

A 16-year-old male comes to your office for a routine check-up.  He was diagnosed with asthma six months ago and started on inhaled corticosteroids as well as an albuterol inhaler as needed.  He reports a modest improvement in his symptoms using this regimen.  He has no complaints currently.  Physical examination reveals white plaques on his buccal mucosa that can be scraped off, leaving hyperemic spots.  The lungs are clear on auscultation.  Which of the following is the best initial therapy for the oral lesion?

Quizplus · Accepted Answer

Explanation: This patient's oral white plaques are typical for oral candidiasis (thrush). These plaques can typically be removed, although at times it may be difficult. A residual area of inflammation may be seen where the plaque has been removed. Most patients are asymptomatic, although some may complain of a strange, cottony taste in the mouth. The main predisposing factor in this patient is his use of inhaled corticosteroids for asthma. The patient should be observed for proper use of his inhaler, as the thrush may be a sign that he is using it improperly with a large amount of the medicine depositing in his oropharynx as opposed to passing into his lungs. A spacer device may be helpful for the patient if he is having trouble. Candida can also cause esophagitis if the infection progresses, but these patients will typically complain of pain with swallowing (odynophagia). The first-line therapy for oral candidiasis is a topical antifungal, either nystatin suspension or clotrimazole troches. Patients should also be advised to rinse their mouth after using inhaler. (Choice B) Oral fluconazole is an antifungal agent and can be used in cases that are resistant to initial treatment with topical nystatin. (Choice C) Acyclovir is used for infections caused by herpes virus, which is not likely in this patient as the white plaques are essentially diagnostic for thrush. (Choice D) Topical steroids are effective in aphthous stomatitis. However, since steroids initially led to the patient's thrush they would likely only make it worse. (Choice E) Biopsy is reserved for diagnostic dilemmas and for lesions that are concerning for malignancy. Educational objective: The best initial therapy for oral candidiasis (thrush) is a topical antifungal (e.g., nystatin suspension or clotrimazole troches), with an oral antifungal such as fluconazole used for resistant cases. In patients where thrush is secondary to inhaled corticosteroids, proper technique should be assessed by watching the patient use the inhaler.

A 16-Year-Old Male Comes to Your Office for a Routine