Piedra Medication

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

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. [22, 52] Therapy with oral itraconazole for the treatment of uncomplicated white piedra affecting the scalp hair may be a good choice if topical remedies fail. [53]  The combination of topical benzoyl peroxide 5% wash, clindamycin 1% solution, and ketoconazole 2% shampoo successfully treated one Pacific Island patient. [54]

Disseminated trichosporosis can be difficult to treat, but itraconazole is often used. In one study, in vitro interactions of itraconazole with caspofungin suggested enhanced antifungal activity against T asahii; this combination may be of value for treating disseminated trichosporosis. [55]


Antifungal agents

Class Summary

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)

Clotrimazole 1% is often a first-line drug used in the treatment of tinea cruris. It is available by prescription only. Cream, solution or spray, and lotion forms are available.

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

Miconazole 2% is an imidazole used in the treatment of tinea cruris. It is available over the counter. Cream, solution or spray, lotion, and powder forms are available.

Ketoconazole topical (Nizoral cream)

Ketoconazole topical is an imidazole broad-spectrum antifungal agent; it inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Econazole topical (Ecoza)

Econazole 1% is effective in cutaneous infections. It interferes with RNA and protein synthesis and metabolism. It disrupts fungal cell-wall permeability, causing fungal cell death.

Terbinafine (Lamisil)

Terbinafine is an 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.

Oxiconazole 1% (Oxistat)

Oxiconazole 1% damages the fungal cell wall membrane by inhibiting the biosynthesis of ergosterol. It increases membrane permeability, causing nutrients to leak out, resulting in fungal cell death.

Sulconazole 1% (Exelderm)

Sulconazole 1% is a broad-spectrum imidazole derivative with antifungal and antiyeast activity. It is for topical use. It inhibits the growth of common pathogenic dermatophytes.

Itraconazole (Sporanox)

Itraconazole has fungistatic activity. It is a 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 is improved with food and in the 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.

Ciclopirox (Loprox)

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

Naftifine (Naftin)

Naftifine is indicated for tinea corporis, tinea cruris, and tinea pedis. It is a 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 weeks of treatment, reevaluate the patient.


Dermatologic agents

Class Summary

These agents may be effective in treating white piedra.

Selenium sulfide topical (Exsel, Selsun)

Selenium sulfide blocks enzymes involved in the growth of epithelial tissue.

Chlorhexidine (Hibiclens, PerioGard)

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

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

Pyrithione zinc is a cytostatic agent that reduces cell the turnover rate. It strongly binds to hair and external skin layers.