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.^[32]

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.^[33]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.^[34]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.^[35]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.^[36]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.^[37]It is remarkable to have pedicular nits impregnated with spores of white piedra. A mother and daughter both had white piedra, speculated as a result of the use of homemade hair cream.^[38]

Physical Examination

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.

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,^[39]where it can be extensive.^{[40, 41]}

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

Complications

The most common complication is the loss of the structural integrity of the hair shaft, which leads to breakage.

Differential Diagnoses

Beigel H. The Human Hair. Its Structure, Growth, Diseases, and Their Treatment. London, England: Renshaw; 1869.
Singh A, Nyati A, Mohta A, Kushwaha RK, Jain SK. A Case of Scalp White Piedra Caused by Trichosporon Ovoides. Int J Trichology. 2019 May-Jun. 11 (3):134-137. [QxMD MEDLINE Link].
Schwartz RA. Superficial fungal infections. Lancet. 2004 Sep 25-Oct 1. 364(9440):1173-82. [QxMD MEDLINE Link].
Londero AT, Ramos CD, Fischman O. White piedra of unusual localization. Sabouraudia. 1966 Oct. 5(2):132-3. [QxMD MEDLINE Link].
Rippon JW. Medical Mycology. The Pathogenic Fungi and the Pathogenic Actinomycetes. 3rd ed. Philadelphia, Pa: WB Saunders; 1988. 142: 163-8.
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. 2001 Jan 15. 218(2):238-42. [QxMD MEDLINE Link].
Coimbra Junior CE, Santos RV. Black piedra among the Zoró Indians from Amazônia (Brazil). Mycopathologia. 1989 Jul. 107(1):57-60. [QxMD MEDLINE Link].
Kwon-Chung KJ, Bennett JE. Piedra (tinea nodosa trichomycosis nodularis, trichomycosis nodosa, Beigel’s disease, Chignon disease). Medical Mycology. Philadelphia, Pa: Lea & Febiger; 1992. 183-90.
Tendolkar U, Shinde A, Baveja S, Dhurat R, Phiske M. Trichosporon inkin and Trichosporon mucoides as unusual causes of white piedra of scalp hair. Indian J Dermatol Venereol Leprol. 2014 Jul-Aug. 80(4):324-7. [QxMD MEDLINE Link].
Fischman O, Bezerra FC, Francisco EC, da Silva FC, Nishikaku AS, Cavalcanti SD, et al. Trichosporon inkin: an uncommon agent of scalp white piedra. Report of four cases in Brazilian children. Mycopathologia. 2014 Aug. 178(1-2):85-9. [QxMD MEDLINE Link].
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. 2002 Jul. 97(5):747-50. [QxMD MEDLINE Link].
Mugge C, Haustein UF, Nenoff P. [Causative agents of onychomycosis--a retrospective study]. J Dtsch Dermatol Ges. 2006 Mar. 4(3):218-28. [QxMD MEDLINE Link].
Ortega-Springall MF, Arroyo-Escalante S, Arenas R. Onycholysis and Chromonychia: A Case Caused by Trichosporon inkin. Skin Appendage Disord. 2016 Feb. 1 (3):144-6. [QxMD MEDLINE Link].
Magalhães AR, Nishikawa MM, Mondino SS, Macedo HW, Rocha EM, Baptista AR. Trichosporon isolation from human ungueal infections: is there a pathogenic role?. An Bras Dermatol. 2016 Apr. 91 (2):173-9. [QxMD MEDLINE Link].
Karabay O, Madariaga MG, Kocoglu E, Ince N, Kandirali E. Trichosporon asahii fungemia in a patient with non-hematological malignancy. Jpn J Infect Dis. 2006 Apr. 59(2):129-31. [QxMD MEDLINE Link].
Bayramoglu G, Sonmez M, Tosun I, Aydin K, Aydin F. Breakthrough Trichosporon asahii fungemia in neutropenic patient with acute leukemia while receiving caspofungin. Infection. 2008 Feb. 36(1):68-70. [QxMD MEDLINE Link].
Elmer KB, Elston DM, Libow LF. Trichosporon beigelii infection presenting as white piedra and onychomycosis in the same patient. Cutis. 2002 Oct. 70(4):209-11. [QxMD MEDLINE Link].
Manzano-Gayosso P, Hernandez-Hernandez F, Mendez-Tovar LJ, et al. Onychomycosis incidence in type 2 diabetes mellitus patients. Mycopathologia. 2008 Jul. 166(1):41-5. [QxMD MEDLINE Link].
Gueho E, Improvisi L, de Hoog GS, Dupont B. Trichosporon on humans: a practical account. Mycoses. 1994 Jan-Feb. 37(1-2):3-10. [QxMD MEDLINE Link].
Zeller S, Lempert S, Goebeler M, Hamm H, Kolb-Mäurer A. Cladosporium cladosporioides: a so far unidentified cause of white piedra. Mycoses. 2015 May. 58(5):315-7. [QxMD MEDLINE Link].
Magalhaes AR, Mondino SS, Silva M, Nishikawa MM. Morphological and biochemical characterization of the aetiological agents of white piedra. Mem Inst Oswaldo Cruz. 2008 Dec. 103(8):786-90. [QxMD MEDLINE Link].
Kiken DA, Sekaran A, Antaya RJ, Davis A, Imaeda S, Silverberg NB. White piedra in children. J Am Acad Dermatol. 2006 Dec. 55(6):956-61. [QxMD MEDLINE Link].
Goldberg LJ, Wise E, Miller NS. White piedra in a northern climate caused by Trichosporon inkin: A report of two cases. Br J Dermatol. 2015 Apr 2. [QxMD MEDLINE Link].
Fischman O. Black piedra among Brazilian Indians. Rev Inst Med Trop Sao Paulo. 1973 Mar-Apr. 15(2):103-6. [QxMD MEDLINE Link].
Kubec K, Dvorak R, Alsaleh QA. Trichosporosis (white piedra) in Kuwait. Int J Dermatol. 1998 Mar. 37(3):186-7. [QxMD MEDLINE Link].
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. 1994 Jul-Aug. 37(7-8):249-53. [QxMD MEDLINE Link].
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. 2008 Sep-Oct. 50(5):307-9. [QxMD MEDLINE Link].
Desai DH, Nadkarni NJ. Piedra: an ethnicity-related trichosis?. Int J Dermatol. 2013 Jun 20. [QxMD MEDLINE Link].
Kalter DC, Tschen JA, Cernoch PL, et al. Genital white piedra: epidemiology, microbiology, and therapy. J Am Acad Dermatol. 1986 Jun. 14(6):982-93. [QxMD MEDLINE Link].
Obana Y, Sano M, Jike T, Homma T, Nemoto N. Differential diagnosis of trichosporonosis using conventional histopathological stains and electron microscopy. Histopathology. 2010 Feb. 56(3):372-83. [QxMD MEDLINE Link].
Milan EP, Silva-Rocha WP, de Almeida JJS, Fernandes TUG, de Araújo Prudente AL, de Azevedo MF, et al. Trichosporon inkin meningitis in Northeast Brazil: first case report and review of the literature. BMC Infect Dis. 2018 Sep 18. 18 (1):470. [QxMD MEDLINE Link].
Elgart ML. Unusual subcutaneous infections. Dermatol Clin. 1996 Jan. 14(1):105-11. [QxMD MEDLINE Link].
Lascaux AS, Bouscarat F, Descamps V, et al. [Cutaneous manifestations during disseminated trichosporonosis in an AIDS patient]. Ann Dermatol Venereol. 1998 Feb. 125(2):111-3. [QxMD MEDLINE Link].
Moyer DG, Keeler C. Nnote on culture of black peidra for cosmetic reasons. Arch Dermatol. 1964 Mar. 89:436. [QxMD MEDLINE Link].
Youker SR, Andreozzi RJ, Appelbaum PC, Credito K, Miller JJ. White piedra: further evidence of a synergistic infection. J Am Acad Dermatol. 2003 Oct. 49(4):746-9. [QxMD MEDLINE Link].
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. 2004 Feb. 42(1):87-92. [QxMD MEDLINE Link].
Ghorpade A. Surrogate nits impregnated with white piedra--a case report. J Eur Acad Dermatol Venereol. 2004 Jul. 18(4):474-6. [QxMD MEDLINE Link].
Borsato BB, Colmiran IR, Silva IC, Rui EF, Pavezzi PD. Mother-daughter white piedra coinfection: a result of homemade hair cream use?. Int J Dermatol. 2020 Dec 15. [QxMD MEDLINE Link].
Viswanath V, Kriplani D, Miskeen AK, Patel B, Torsekar RG. White piedra of scalp hair by Trichosporon inkin. Indian J Dermatol Venereol Leprol. 2011 Sep-Oct. 77(5):591-3. [QxMD MEDLINE Link].
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. 2011 Dec. 172(6):481-6. [QxMD MEDLINE Link].
Ramírez-Soto MC, Andagua-Castro J, Quispe MA, Aguilar-Ancori EG. Cases of white piedra of the hair on the American continent: a case report and a systematic literature review. J Eur Acad Dermatol Venereol. 2019 Jan. 33 (1):e14-e16. [QxMD MEDLINE Link].
Child Health Alert. Head lice vs. white piedra: something to consider. Child Health Alert. 2007 Jan. 25:1. [QxMD MEDLINE Link].
Lebwohl M, Clark L, Levitt J. Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics. 2007 May. 119(5):965-74. [QxMD MEDLINE Link].
Cervantes J, Johr RJ, Tosti A. Dermoscopy of yellow concretions on axillary hair. Skin Appendage Disord. 2018. 4:86-89.
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. 2000 May. 42(5 Pt 2):929-31. [QxMD MEDLINE Link].
Zhuang K, Ran X, Dai Y, Tang J, Yang Q, Pradhan S, et al. An Unusual Case of White Piedra Due to Trichosporon inkin Mimicking Trichobacteriosis. Mycopathologia. 2016 Dec. 181 (11-12):909-914. [QxMD MEDLINE Link].
Landero J. Long-term pubic dermatitis diagnosed as white piedra. Cutis. 2017 Dec. 100 (6):448-450. [QxMD MEDLINE Link].
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. 1987 Jul-Aug. 29(4):251-2. [QxMD MEDLINE Link].
Richini-Pereira VB, Camargo RM, Bagagli E, Marques SA. White piedra: molecular identification of Trichosporon inkin in members of the same family. Rev Soc Bras Med Trop. 2012 Jun. 45(3):402-4. [QxMD MEDLINE Link].
Hay RJ, Moore M. Mycology. Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science; 1998. 1291-3.
Roberts SOB, Hay RJ, Mackenzie DWR. The superficial mycoses: tropical superficial infections. A Clinician's Guide to Fungal Disease. New York, NY: Marcel Dekker; 1984. 92-4.
Bieber AK, Pomeranz MK, Kim RH. White Piedra. JAMA Dermatol. 2021 Mar 1. 157 (3):339. [QxMD MEDLINE Link].
Khandpur S, Reddy BS. Itraconazole therapy for white piedra affecting scalp hair. J Am Acad Dermatol. 2002 Sep. 47(3):415-8. [QxMD MEDLINE Link].
Kumetz EA, Rivard SC. Image Gallery: White piedra. Br J Dermatol. 2020 Mar. 182 (3):e86. [QxMD MEDLINE Link].
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. 2011 May. 171(5):345-8. [QxMD MEDLINE Link].

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Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

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, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

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

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

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: Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Dermatology Association, American Academy of Dermatology, American Society for Clinical Pharmacology and Therapeutics

Disclosure: Nothing to disclose.

Piedra Clinical Presentation

History

Physical Examination

Complications

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