eMedicine Specialties > Dermatology > Fungal Infections

Piedra: Differential Diagnoses & Workup

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Rachel Altman, MD, Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Jun 12, 2009

Differential Diagnoses

Lice
Monilethrix
Tinea Capitis
Trichomycosis Axillaris
Trichorrhexis Nodosa

Other Problems to Be Considered

Pediculosis
Nits28,29
Hair casts
Developmental defects of the hair shaft
Trichomycosis axillaris infection: Unlike the organisms that cause piedra, T axillaris fluoresces under ultraviolet illumination.
Tinea capitis: Unlike piedra, tinea capitis affects the base of the hair shaft and the follicle.
Monilethrix, trichorrhexis nodosa, and trichoptilosis: White piedra can be clinically indistinguishable from these conditions.
Hand eczema: This condition is a superficial infection caused by Trichosporon species that can mimic hand eczema in one who is immunocompromised.30

Workup

Laboratory Studies

  • Staining
    • Place hair shaft nodules into a 10-15% potassium hydroxide preparation on a glass slide. A fungal stain, such as chlorazol black E stain or Parker blue-black ink may be added to highlight the hyphae.
    • If the nodule is from black piedra, tightly packed and pigmented hyphae, asci, and ascospores are seen attached to the hair shaft.
    • If the nodule is from white piedra, darkly stained and loosely arranged hyphae, blastoconidia, and arthroconidia are seen attached to the hair shaft.
  • Culturing
    • P hortae, the cause of black piedra, grows slowly on Sabouraud dextrose agar and is not inhibited by cycloheximide. Microscopic examination reveals septate hyphae, chlamydospores, and irregularly shaped hyphal elements.31 These cultures are of the asexual phase of the fungus. Organisms in the sexual phase are difficult to grow in culture.
    • T asahii, the typical cause of white piedra, rarely grows on Sabouraud dextrose agar because of inhibition by cycloheximide, which is present in dermatophyte test medium and in Mycosel and mycobiotic agars. In addition, Trichosporon species grow best at 28-30°C.

Histologic Findings

In black piedra, the dark nodules are composed of different components based on the area of the body in which they are located. Black piedra is distinguished by ascospores borne in a subglobose ascus in groups of 8. The periphery of the nodule has regularly aligned hyphae and arthroconidia.32 P hortae is one of the few pathogenic human fungi that produce sexual spores in its parasitic phase.

White piedra is characterized by discrete-to-coalesced nodules that typically are white, cream, or brown.17,33 Nodules on the hair shaft often appear amorphous, but may be outlined by hyaline arthroconidia, 2-4 septate hyphae, and differentiated blastoconidia that arise from loosely packed hyphae. Sexual spores are not known to be present.17 Fungal structures stain easily with Parker blue-black ink.

More on Piedra

Overview: Piedra
Differential Diagnoses & Workup: Piedra
Treatment & Medication: Piedra
Follow-up: Piedra
References
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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. 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].

  25. 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].

  26. 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].

  27. 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].

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

  29. 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].

  30. 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].

  31. 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].

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

  33. 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.

  34. [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].

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

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

  37. 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.

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

  39. 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].

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

  41. 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].

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Further Reading

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Keywords

black piedra, white piedra, trichosporosis, asymptomatic superficial fungal infection of the hair shaft, Pleurococcus beigelii, P beigelii, Trichosporon beigelii, T beigelii, Piedraia hortae, P hortae, Trichosporon cutaneum, T cutaneum

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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, UMDNJ-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.

Medical Editor

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.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
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.

Managing Editor

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, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

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, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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