eMedicine Specialties > Dermatology > Fungal Infections

Piedra: Treatment & Medication

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

Treatment

Medical Care

Shaving or cutting the hair is the treatment of choice. Antifungal agents and terbinafine also are used in the treatment of piedra.

  • Black piedra is treated by using oral terbinafine.
  • White piedra can be treated by using topical antifungals, including imidazoles, ciclopirox olamine, 2% selenium sulfide, 6% precipitated sulfur in petroleum, chlorhexidine solution, Castellani paint, zinc pyrithione, and amphotericin B lotion.
  • The American Academy of Dermatology has published guidelines for treating this superficial mycotic infection.34

Medication

Treatment of white piedra can be a therapeutic challenge. Several topical and systemic antifungal agents may not eradicate the disorder. However, they should be tried, as scalp and hair infection may sometimes be successfully treated with a combination of oral azole antifungals and shampoos without shaving the scalp.12 Therapy with oral itraconazole for the treatment of uncomplicated white piedra affecting the scalp hair may be a good choice if topical remedies fail.35

Antifungal agents

The mechanism of action of antifungals may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.


Clotrimazole 1% (Lotrimin, Mycelex)

Often a first-line drug used in the treatment of tinea cruris. Available by prescription only. Cream, solution or spray, and lotion forms are available.

Adult

Apply topically to affected areas bid for 4 wk or until condition resolves

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not for treatment of systemic fungal infections; avoid contact with eyes; if irritation or sensitivity develops, discontinue and initiate appropriate therapy


Miconazole 2% (Micatin, Monistat-Derm, Femizole-7, Lotrimin)

Imidazole used in the treatment of tinea cruris. Available over the counter. Cream, solution or spray, lotion, and powder forms are available.

Adult

Apply topically to affected areas bid for 4 wk or until condition resolves

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes


Ketoconazole 2% cream (Nizoral cream)

Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Adult

Apply topically to affected areas qd for 2-4 wk or until condition resolves

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue if sensitivity or irritation develops; for external use only; avoid contact with eyes


Econazole 1% (Spectazole)

Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell-wall permeability, causing fungal cell death.

Adult

Apply topically to affected areas qd until condition resolves

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue if sensitivity or irritation develops; for external use only; avoid contact with eyes


Terbinafine (Lamisil)

Allylamine derivative that inhibits squalene epoxidase, a key enzyme in sterol biosynthesis in fungi. This inhibition results in a deficiency in ergosterol within the fungal cell wall that causes fungal cell death. Terbinafine is available by prescription only. Some clinicians reserve the use of this drug for more widespread and/or resistant infections because of its broad coverage and cost. This medication is effective and well tolerated in children.

Adult

White piedra: Apply topically to the affected area qd for 2 wk or until condition resolves
Black piedra: 250 mg/d PO; not to exceed 12 wk

Pediatric

Topical: Administer as in adults
Oral:
12-20 kg: 62.5 mg/d
20-40 kg: 125 mg/d
>40 kg: 250 mg/d
Treatment duration as in adults

Possible interactions with drugs metabolized by the CYP-450 (P-450) 2D6 enzyme (eg, tricyclic antidepressants, propranolol, theophylline); may decrease cyclosporin levels; rifampin increases clearance; cimetidine may increase toxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce oral dose in renal insufficiency; discontinue if hepatobiliary dysfunction, neutropenia, Stevens-Johnson syndrome, or changes in ocular lens or retina develop; discontinue topical use if chemical irritation develops
Monitor patient response and adjust caffeine dosage during combined treatment with terbinafine; observe for signs of caffeine toxicity (headache, agitation, insomnia, diuresis, fever)


Oxiconazole 1% (Oxistat)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Increases membrane permeability, causing nutrients to leak out, resulting in fungal cell death.

Adult

Apply to affected area qd/bid until condition resolves

Pediatric

Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes


Sulconazole 1% (Exelderm)

Broad-spectrum imidazole derivative with antifungal and antiyeast activity. For topical use. Inhibits growth of common pathogenic dermatophytes.

Adult

Apply to affected areas qd/bid for 2-4 wk or until condition resolves

Pediatric

Not established

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes


Itraconazole (Sporanox)

Fungistatic activity. Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Absorption improved with food and in presence of normal gastric acidity. Patients should be cautioned against ingesting grapefruit juice while on itraconazole therapy (decreased oral bioavailability of itraconazole). Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes.

Adult

100 mg PO qd until culture negativity achieved

Pediatric

Not established

As CYP3A4 inhibitor (P450 metabolism), many drugs have interactions when coadministered with itraconazole; avoid alcohol use because disulfiramlike reaction may occur; antacids may reduce absorption; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; high doses may increase tacrolimus and cyclosporine plasma concentrations; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (eg, lovastatin, simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce levels (phenytoin metabolism may be altered)
Reduced itraconazole plasma concentrations reported with concurrent use of H2 antagonist and aluminum-, calcium-, or magnesium-containing products (administer aluminum-, calcium-, or magnesium-containing products at least 1 h before or 2 h after itraconazole cap); enhances anticoagulant effects of coumarinlike drugs

Documented hypersensitivity; congestive heart failure or history of congestive heart failure (itraconazole cap for treatment of superficial fungal infections), concurrent administration with cisapride, midazolam, triazolam, lovastatin, dofetilide, pimozide, levacetylmethadol (levomethadyl), quinidine, lovastatin, simvastatin, and ergot alkaloids metabolized by CYP3A4 (eg, dihydroergotamine, ergometrine [ergonovine], ergotamine, methylergometrine [methylergonovine]); women contemplating pregnancy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic insufficiencies; adverse effects include headache, nausea, vomiting, reversible elevation of liver enzyme levels, hepatotoxicity, hallucinations, hypokalemia, heart failure, edema, congestive heart failure, and neutropenic disorder; oral solution and oral capsules not to be used interchangeably; injection not for use in patients with CrCl <30 mL/min, and use with caution in patients with CrCl of 30-80 mL/min


Ciclopirox (Loprox)

Interferes with DNA, RNA, and protein synthesis by inhibiting the transport of essential elements in fungal cells.

Adult

Massage into affected area bid until condition resolves

Pediatric

Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Avoid contact with eyes and other internal routes


Naftifine (Naftin)

Indicated for the treatment of tinea corporis, tinea cruris, and tinea pedis. Broad-spectrum antifungal agent that appears to interfere with sterol biosynthesis by inhibiting the enzyme squalene 2,3-epoxidase. This inhibition results in decreased amounts of sterols, causing cell death. If no clinical improvement occurs after 4 wk of treatment, reevaluate patient.

Adult

Gently and sparingly massage the cream or gel into affected area and surrounding skin qd/bid for 2-4 wk or until condition resolves

Pediatric

Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue use if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes

Dermatologic agents

These agents may be effective in treating white piedra.


Selenium sulfide 1-2.5% lotion (Exsel, Selsun)

Blocks enzymes involved in growth of epithelial tissue.

Adult

Massage for 5-10 min into wet hair, wait for 2-3 min, then rinse; repeat application and rinse; wash hands after treatment; qd until resolved

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

To avoid systemic toxicity, do not use in broken or open skin; avoid use in very young children


Carbol-fuchsin (Castellani Paint)

First-aid antiseptic and drying agent. Active ingredient is phenol 1.5%. Inactive ingredients are water, SD alcohol 40B (13%), resorcinol, acetone, and basic fuchsin.

Adult

Spray or apply to affected area qd/bid

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid contact with clothing; stain slowly wears off; not for application on eroded skin, or large areas; infants may be more sensitive than adults to phenol component


Chlorhexidine (Hibiclens, PerioGard)

Effective, relatively safe, and reliable topical antiseptic. A polybiguanide with bactericidal activity; usually is supplied as a gluconate salt. At physiologic pH, the salt dissociates to a cation that binds to bacterial cell walls.

Adult

Rinse affected area with water, apply sufficient amount to cover affected area, wash gently, then rinse

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Corneal damage may occur; skin irritation, ototoxicity resulting in deafness (when used around the ear), phototoxicity, and/or allergic reactions rare when used to clean superficial wounds (does not cause additional tissue injury or delay healing)


Pyrithione zinc (DHS Zinc, Zincon, Head & Shoulders)

Cytostatic agent that reduces cell turnover rate. Strongly binds to hair and external skin layers.

Adult

Apply shampoo and rinse; use qd until condition resolves; use as with selenium sulfide

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For external use only; do not apply to eyes

More on Piedra

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