What should I do about cough caused by fungal pharyngitis?

Fungal pharyngitis—most commonly caused by Candida albicans—is a relatively uncommon but clinically important cause of sore throat and associated cough, particularly in immunocompromised individuals, those on prolonged antibiotic or corticosteroid therapy, or patients with uncontrolled diabetes mellitus. The cough is typically secondary to postnasal drip, mucosal irritation, or laryngeal involvement rather than direct fungal invasion of the lower airways.

Management begins with accurate diagnosis: clinical suspicion should be confirmed via oropharyngeal swab with fungal culture and/or potassium hydroxide (KOH) preparation demonstrating pseudohyphae and budding yeast. In atypical or refractory cases, endoscopic evaluation with biopsy may be warranted to rule out other etiologies such as malignancy or granulomatous disease.

First-line treatment is topical antifungal therapy—nystatin oral suspension (100,000–600,000 units/mL), swished and swallowed four times daily for 7–14 days, or clotrimazole troches (10 mg five times daily). For moderate-to-severe or recurrent cases—especially in immunocompromised hosts—systemic antifungals such as fluconazole (100–200 mg orally once daily for 7–14 days) are indicated. Itraconazole or posaconazole may be considered in fluconazole-resistant strains or complex host factors.

Concurrently, address underlying predisposing factors: optimize glycemic control in diabetic patients; discontinue unnecessary antibiotics or inhaled corticosteroids (or ensure proper inhaler technique and post-inhalation mouth rinsing); and assess for HIV or other immunodeficiencies if not previously evaluated. Supportive measures—including adequate hydration, saline gargles, and avoidance of irritants like tobacco smoke—can help alleviate cough and promote mucosal healing.

Patients should be re-evaluated within 1 week of initiating therapy. Persistent or worsening symptoms warrant reassessment for treatment adherence, drug resistance, alternative diagnoses (e.g., reflux laryngopharyngitis, eosinophilic esophagitis), or progression to invasive fungal infection—particularly in high-risk populations.