A 28-year-old woman with mild persistent asthma has been using salbutamol inhaler 4–5 times per week for the past 3 months. She is now prescribed fluticasone propionate 110 µg inhaled twice daily. After 2 weeks of therapy, she reports hoarseness of voice and white patches in the oral cavity. On examination, white plaques are seen on the tongue and palate that do not wipe off easily. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis The patient has developed **oral candidiasis** (thrush) — a well-recognized local adverse effect of inhaled corticosteroids (ICS). The white plaques on the tongue and palate that **do not wipe off easily** are characteristic of candidal infection (as opposed to oral leukoplakia or milk residue, which wipe off). ## Pathophysiology of ICS-Related Candidiasis **Key Point:** Inhaled corticosteroids suppress local mucosal immunity in the oropharynx, permitting opportunistic colonization by *Candida albicans*. The incidence is approximately 5–10% with standard dosing and rises with higher doses or poor inhaler technique. ## Why Active Candidiasis Requires Antifungal Treatment Once oral candidiasis is **established and symptomatic** (hoarseness + visible plaques), mouth rinsing alone is insufficient — it is a **preventive** measure, not a treatment for active infection. The correct immediate management is: 1. **Treat the active infection** with an antifungal (oral miconazole gel/suspension or nystatin suspension). 2. **Continue fluticasone** — ICS is the cornerstone of persistent asthma control; withdrawal risks exacerbation. 3. **Counsel on mouth rinsing** after each inhalation and spacer use to prevent recurrence. | Option | Rationale | |--------|-----------| | **Oral miconazole + continue fluticasone** ✓ | Treats active infection; preserves asthma control | | Discontinue fluticasone | Dangerous — risks asthma exacerbation; not indicated | | Reduce dose + add spacer | Appropriate for prevention/recurrence, not acute treatment | | Mouth rinse only | Preventive measure; inadequate for established infection | **High-Yield:** According to standard guidelines (BTS/SIGN, GINA), **established symptomatic oral candidiasis** due to ICS should be treated with a topical antifungal (miconazole or nystatin) while the ICS is continued. Mouth rinsing is the primary **prevention** strategy, not the treatment for active disease. ## Clinical Pearl **Clinical Pearl:** Do not confuse prevention with treatment. Rinsing after inhalation prevents candidiasis; once plaques are present and symptomatic, antifungal therapy is required. Fluticasone should never be stopped for a manageable local side effect. ## Correct Management Sequence 1. **Start oral miconazole** suspension (or nystatin) for active candidiasis 2. **Continue fluticasone** at the same dose for asthma control 3. **Educate on mouth rinsing** after every ICS dose (prevention of recurrence) 4. **Add spacer device** to reduce oropharyngeal deposition going forward 5. **Review in 1–2 weeks** for resolution [cite: KD Tripathi 8e Ch 28; GINA 2023 Guidelines; BTS/SIGN British Guideline on the Management of Asthma]