Abstract Device- and mucosa-associated candidiasis is difficult to cure because Candida biofilms shield cells from antifungals, leading to relapse and device failure. Standard treatment decisions are still largely guided by planktonic susceptibility tests, which poorly predict the drug exposure needed to clear mature biofilms. Here we synthesize evidence that natural-compound adjuvants can dismantle key biofilm defenses and outline design rules to rationalize biofilm-aware combination therapy. Across Candida albicans , non- albicans species and Candida auris , the most reproducible adjuvant effects fell into three themes: (1) reprogramming adhesion and morphogenesis, (2) disrupting membrane sterol homeostasis, and (3) weakening the extracellular matrix and efflux-mediated tolerance. When paired with standard antifungals, these actions frequently increase killing of established biofilms and reduce the exposures required for eradication. Local delivery approaches that concentrate actives at mucosal surfaces or device interfaces (nano- or surface-directed formulations) further improve intrabiofilm exposure while limiting systemic toxicity. We conclude that translation will require standardized biofilm assays, species-stratified testing and tighter links between biofilm pharmacology and clinically achievable exposure. The framework presented here is intended to help prioritize natural adjuvants and combinations most likely to benefit device-associated and mucosal candidiasis.
Tuan et al. (2026) studied this question.