Piedra Clinical Presentation

Updated: Mar 26, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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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.



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