Piedra Clinical Presentation

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 22, 2012
 

History

White piedra shows irregular, white, cream-colored, or brown soft nodules or gelatinous sheaths along the hair shaft. They can be easily detached from the hair shaft. White piedra is found in the hair of the beard, moustache, genitals, and axilla. Eyebrow and eyelash involvement can also be present, while on the scalp, white piedra appears to be less common.

Piedra may be asymptomatic in many patients. Patients may not be able to see the minute nodules that haphazardly develop on the hair shaft; however, they may feel the gritty nodules. Patients may hear a metallic sound when they brush their hair.[18]

Assess the immune status of the patient because of the possibility of disseminated infection in a patient who is immunocompromised; T asahii, which is the most typical agent for white piedra, can cause disseminated infection in these patients. These systemic infections occur primarily in patients who have neutropenia and, rarely, in patients with AIDS.[19] Cutaneous disseminated papulae or purpural nodules are frequently present in these patients.

Black piedra may be used as a hair dye to darken hair; at least one San Blas (Panama) Cuna albino Indian chanter has been described as deliberately cultivating black piedra for cosmetic reasons.[20] She was careful to avoid oil use on her scalp, since it apparently removed this fungus.

White piedra may have a synergistic coryneform bacterial infection.[21] White piedra, although not commonly reported to infect scalp hair in North America, is an important consideration in the evaluation of scalp hair concretions. White piedra may affect the scalp, and in one case, it was the only site affected and was extensive.[22] Rarely, Trichosporon species may be accompanied by Candida parapsilosis along hair shafts, although it is unclear if this is really a co-infection.

A peculiar case has been described with white piedra spores packed inside empty pedicular nits were accidentally found on microscopic examination in a 42-year-old Indian woman who presented with hair loss.[23] It is remarkable to have pedicular nits impregnated with spores of white piedra.

Next

Physical

Findings in black piedra may include the following:

  • Black piedra consists of darkly pigmented, firmly attached nodules that vary in size to as large as a few millimeters in diameter. The nodules feel hard.
  • The most commonly affected area of the body is the scalp hair. Black piedra less frequently affects beards, mustaches, and the pubic hair.
  • The fungus grows into the hair shaft; ultimately, it may cause hair breakage because of structural instability.

Findings in white piedra may include the following:

  • White piedra consists of lightly pigmented, loosely attached nodules or gelatinous sheaths that have a soft texture.
  • The most commonly affected areas of the body are beards, mustaches, pubic and axillary hair, and eyelashes and eyebrows. It may rarely appear on the scalp,[24] where it can be extensive.[25]

Hair breakage occurs in both forms of piedra. In both varieties of piedra, the surrounding skin is healthy.

Previous
Next

Causes

T asahii can cause white piedra and occasionally an onychomycosis.[26, 27] The genus Trichosporon Behrend consists of 6 human pathogenic species: T asahii, T mucoides, T ovoides, T asteroides, T cutaneum, and T inkin and all of which belong to the class Basidiomycetes.[8, 28] These species are the causative agents of piedra and other superficial infections as well as mucosa-associated systemic mycosis.[28]

In Brazil Trichosporon ovoides and Trichosporon inkin are common causative agents of white piedra, producing nodules in genital hair or on the scalp.[29] Of Trichosporon species isolated from 10 clinical samples in a 2008 study, T ovoides was predominant, being found in 7 samples, while T inkin was identified just in 2 of them.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Rachel Altman, MD  Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School

Rachel Altman, MD is a member of the following medical societies: Alpha Omega Alpha and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Neil Shear, MD  Professor and Chief of Dermatology, Professor of Medicine, Pediatrics and Pharmacology, University of Toronto Faculty of Medicine; Head of Dermatology, Sunnybrook Women's College Health Sciences Center and Women's College Hospital, Canada

Neil Shear, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Clinical Pharmacology and Therapeutics, Canadian Dermatology Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Christen M Mowad, MD  Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Dermatological Association, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Beigel H. The Human Hair. In: Its Structure, Growth, Diseases, and Their Treatment. London, England: Renshaw; 1869.

  2. Schwartz RA. Superficial fungal infections. Lancet. Sep 25-Oct 1 2004;364(9440):1173-82. [Medline].

  3. Londero AT, Ramos CD, Fischman O. White piedra of unusual localization. Sabouraudia. Oct 1966;5(2):132-3. [Medline].

  4. Rippon JW. Medical Mycology. In: The Pathogenic Fungi and the Pathogenic Actinomycetes. 142. 3rd ed. Philadelphia, Pa: WB Saunders; 1988:163-8.

  5. González RN, Wilson DJ, Sickles SA, Zurakowski MJ, Weybrecht PM, Walsh AK. Outbreaks of clinical mastitis caused by Trichosporon beigelii in dairy herds. J Am Vet Med Assoc. Jan 15 2001;218(2):238-42. [Medline].

  6. Coimbra Junior CE, Santos RV. Black piedra among the Zoró Indians from Amazônia (Brazil). Mycopathologia. Jul 1989;107(1):57-60. [Medline].

  7. Kwon-Chung KJ, Bennett JE. Piedra (tinea nodosa trichomycosis nodularis, trichomycosis nodosa, Beigel's disease, Chignon disease). In: Medical Mycology. Philadelphia, Pa: Lea & Febiger; 1992:183-90.

  8. Pontes ZB, Ramos AL, Lima Ede O, Guerra Mde F, Oliveira NM, Santos JP. Clinical and mycological study of scalp white piedra in the State of Paraíba, Brazil. Mem Inst Oswaldo Cruz. Jul 2002;97(5):747-50. [Medline].

  9. Mugge C, Haustein UF, Nenoff P. [Causative agents of onychomycosis--a retrospective study]. J Dtsch Dermatol Ges. Mar 2006;4(3):218-28. [Medline].

  10. Karabay O, Madariaga MG, Kocoglu E, Ince N, Kandirali E. Trichosporon asahii fungemia in a patient with non-hematological malignancy. Jpn J Infect Dis. Apr 2006;59(2):129-31. [Medline].

  11. Bayramoglu G, Sonmez M, Tosun I, Aydin K, Aydin F. Breakthrough Trichosporon asahii fungemia in neutropenic patient with acute leukemia while receiving caspofungin. Infection. Feb 2008;36(1):68-70. [Medline].

  12. Kiken DA, Sekaran A, Antaya RJ, Davis A, Imaeda S, Silverberg NB. White piedra in children. J Am Acad Dermatol. Dec 2006;55(6):956-61. [Medline].

  13. Fischman O. Black piedra among Brazilian Indians. Rev Inst Med Trop Sao Paulo. Mar-Apr 1973;15(2):103-6. [Medline].

  14. Kubec K, Dvorak R, Alsaleh QA. Trichosporosis (white piedra) in Kuwait. Int J Dermatol. Mar 1998;37(3):186-7. [Medline].

  15. Therizol-Ferly M, Kombila M, Gomez de Diaz M, Duong TH, Richard-Lenoble D. White piedra and Trichosporon species in equatorial Africa. I. History and clinical aspects: an analysis of 449 superficial inguinal specimens. Mycoses. Jul-Aug 1994;37(7-8):249-53. [Medline].

  16. Roselino AM, Seixas AB, Thomazini JA, Maffei CM. An outbreak of scalp white piedra in a Brazilian children day care. Rev Inst Med Trop Sao Paulo. Sep-Oct 2008;50(5):307-9. [Medline].

  17. Kalter DC, Tschen JA, Cernoch PL, et al. Genital white piedra: epidemiology, microbiology, and therapy. J Am Acad Dermatol. Jun 1986;14(6):982-93. [Medline].

  18. Elgart ML. Unusual subcutaneous infections. Dermatol Clin. Jan 1996;14(1):105-11. [Medline].

  19. Lascaux AS, Bouscarat F, Descamps V, et al. [Cutaneous manifestations during disseminated trichosporonosis in an AIDS patient]. Ann Dermatol Venereol. Feb 1998;125(2):111-3. [Medline].

  20. Moyer DG, Keeler C. Nnote on culture of black peidra for cosmetic reasons. Arch Dermatol. Mar 1964;89:436. [Medline].

  21. Youker SR, Andreozzi RJ, Appelbaum PC, Credito K, Miller JJ. White piedra: further evidence of a synergistic infection. J Am Acad Dermatol. Oct 2003;49(4):746-9. [Medline].

  22. Taj-Aldeen SJ, Al-Ansari HI, Boekhout T, Theelen B. Co-isolation of Trichosporon inkin and Candida parapsilosis from a scalp white piedra case. Med Mycol. Feb 2004;42(1):87-92. [Medline].

  23. Ghorpade A. Surrogate nits impregnated with white piedra--a case report. J Eur Acad Dermatol Venereol. Jul 2004;18(4):474-6. [Medline].

  24. Viswanath V, Kriplani D, Miskeen AK, Patel B, Torsekar RG. White piedra of scalp hair by Trichosporon inkin. Indian J Dermatol Venereol Leprol. Sep-Oct 2011;77(5):591-3. [Medline].

  25. Shivaprakash MR, Singh G, Gupta P, Dhaliwal M, Kanwar AJ, Chakrabarti A. Extensive white piedra of the scalp caused by Trichosporon inkin: A case report and review of literature. Mycopathologia. Dec 2011;172(6):481-6. [Medline].

  26. Elmer KB, Elston DM, Libow LF. Trichosporon beigelii infection presenting as white piedra and onychomycosis in the same patient. Cutis. Oct 2002;70(4):209-11. [Medline].

  27. Manzano-Gayosso P, Hernandez-Hernandez F, Mendez-Tovar LJ, et al. Onychomycosis incidence in type 2 diabetes mellitus patients. Mycopathologia. Jul 2008;166(1):41-5. [Medline].

  28. Gueho E, Improvisi L, de Hoog GS, Dupont B. Trichosporon on humans: a practical account. Mycoses. Jan-Feb 1994;37(1-2):3-10. [Medline].

  29. Magalhaes AR, Mondino SS, Silva M, Nishikawa MM. Morphological and biochemical characterization of the aetiological agents of white piedra. Mem Inst Oswaldo Cruz. Dec 2008;103(8):786-90. [Medline].

  30. Child Health Alert. Head lice vs. white piedra: something to consider. Child Health Alert. Jan 2007;25:1. [Medline].

  31. Lebwohl M, Clark L, Levitt J. Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics. May 2007;119(5):965-74. [Medline].

  32. Nakagawa T, Nakashima K, Takaiwa T, Negayama K. Trichosporon cutaneum (Trichosporon asahii) infection mimicking hand eczema in a patient with leukemia. J Am Acad Dermatol. May 2000;42(5 Pt 2):929-31. [Medline].

  33. Castro RM, Jaeger RG, Talhari S, de Araujo NS. [Black piedra: the study of its etiological agent using scanning electron microscopy]. Rev Inst Med Trop Sao Paulo. Jul-Aug 1987;29(4):251-2. [Medline].

  34. Hay RJ, Moore M. Mycology. In: Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science; 1998:1291-3.

  35. Roberts SOB, Hay RJ, Mackenzie DWR. The superficial mycoses: tropical superficial infections. In: A Clinician's Guide to Fungal Disease. New York, NY: Marcel Dekker; 1984:92-4.

  36. [Guideline] American Academy of Dermatology, Guidelines/Outcomes Committee. Guidelines of care for superficial mycotic infections of the skin: Piedra. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. Jan 1996;34(1):122-4. [Medline].

  37. Khandpur S, Reddy BS. Itraconazole therapy for white piedra affecting scalp hair. J Am Acad Dermatol. Sep 2002;47(3):415-8. [Medline].

  38. Li H, Qiao J, Wan Z, Zhang J. In Vitro Interaction of Itraconazole with Amphotericin B, Caspofungin, and Terbinafine Against Clinical Isolates of Trichosporon asahii. Mycopathologia. May 2011;171(5):345-8. [Medline].

  39. Obana Y, Sano M, Jike T, Homma T, Nemoto N. Differential diagnosis of trichosporonosis using conventional histopathological stains and electron microscopy. Histopathology. Feb 2010;56(3):372-83. [Medline].

  40. Figueras MJ, Guarro J, Zaror L. New findings in black piedra infection. Br J Dermatol. Jul 1996;135(1):157-8. [Medline].

  41. Fischman O, Pires de Camargo Z, Meireles MCA. Genital white piedra: an emerging fungal disease? 5th International Conference on Mycoses. PAHO Sci Publ. 1989;396:70-6.

  42. Fishman HC. White piedra. Int J Dermatol. Oct 1987;26(8):538. [Medline].

  43. Gueho E, Faergemann J, Lyman C, Anaissie EJ. Malassezia and Trichosporon: two emerging pathogenic basidiomycetous yeast-like fungi. J Med Vet Mycol. 1994;32 Suppl 1:367-78. [Medline].

  44. Odom RB, James WD, Berger TG. Andrews' Diseases of the Skin: Clinical Dermatology. 9th ed. Philadelphia, Pa: WB Saunders; 2000:387-8.

  45. Sugita T, Nishikawa A, Ichikawa T, Ikeda R, Shinoda T. Isolation of Trichosporon asahii from environmental materials. Med Mycol. Feb 2000;38(1):27-30. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.