|Year : 2013 | Volume
| Issue : 4 | Page : 220-223
Nodules on the hair: A rare case of mixed piedra
Swapna S Khatu1, Shital Amin Poojary2, Niranjan G Nagpur2
1 Department of Dermatology, Smt. Kashibai Navale Medical College, Narhe, Pune, India
2 Department of Dermatology, K.J. Somaiya Medical College, Sion, Mumbai, Maharashtra, India
|Date of Web Publication||11-Apr-2014|
Shital Amin Poojary
A-401, Veena Vihar, Datta Mandir Road, Dahanukar Wadi, Kandivali (West), Mumbai - 400 067, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Piedra is a superficial fungal infection of the hair shaft characterized by nodules along the hair shaft. Black piedra affects the scalp hair more frequently than white piedra. Occurrence of both types of piedra simultaneously in a patient is extremely rare. We describe here a rare case of mixed piedra of scalp hair.
Keywords: Black, mixed, piedra, white
|How to cite this article:|
Khatu SS, Poojary SA, Nagpur NG. Nodules on the hair: A rare case of mixed piedra. Int J Trichol 2013;5:220-3
| Introduction|| |
Piedra is a superficial fungal infection of the hair shaft. The two types of piedra, white piedra and black piedra are caused by fungi of the genera Trichosporon and Piedraia respectively. , Typically, black piedra affects the scalp hair, while white piedra tends to affect facial, axillary and pubic hair. We report a rare case of mixed piedra of the scalp hair.
| Case Report|| |
A 40-year-old married female hailing from West Bengal came with the complaints of difficulty in combing hair and blackish small nodules attached to her scalp hair. There was no history of hair loss. There was no family history of similar complaints. Patient gave a history of similar symptoms 5 years back, which had resolved by using antifungal shampoo for 3 months.
Examination of scalp hair revealed multiple discrete firms to hard, brown to black tiny nodules attached to hair shaft. These nodules were distributed irregularly along the length of hair shaft [Figure 1]. When pulled between the fingers, these hairs gave a raspy sensation. Patient also had concurrent nits suggestive of pediculosis capitis. Examination of underlying scalp was normal. Axillary and pubic hair were normal. A provisional diagnosis of black piedra was made. 10% potassium hydroxide (KOH) examination was done from multiple nodules, which surprisingly revealed two different set of findings. Examination of black colored nodule revealed a concretion forming a collar around normal hair shaft, which was made up of filamentous hyphae, held together by cement like substance with spores seen at the edges of the nodule [Figure 2]a. Crushing of nodule by gentle pressure revealed presence of brown dematiaceous closely septate hyphae with few chlamydospores on KOH mount [Figure 2]b. Culture from black colored nodule on the Sabouraud's dextrose agar at room temperature grew small, compact, blackish conical colonies with velvety surface [Figure 2]c. The reverse side of the colonies also revealed black color. One of the colonies, on microscopic examination revealed round, dark brown, globus ascus confirmatory for Piedraia hortae species [Figure 2]d. KOH mount of brown colored nodule revealed nondematiaceous, loosely arranged septate hyphae with arthroconidia and blastoconidia [Figure 3]a. Culture from the brown colored nodule grew white to cream colored, wrinkled, velvety, dull colonies with a mycelial fringe surrounding the hair shaft [Figure 3]b. Lactophenol cotton blue mount from the fungal colonies showed multiple hyaline septate hyphae and arthrospores confirming Trichosporon sp. [Figure 3]c. Thus microscopic and culture characteristics confirmed presence of both black-and-white piedra, i.e., mixed piedra. Presence of nits of Pediculus capitis was also confirmed on microscopy [Figure 4]. Patient was advised trimming of her hair and application of 2% ketoconazole lotion once a week for 3 months resulting in disappearance of the nodules. Patient was also treated with 1% permethrin (single application) for treatment of pediculosis capitis.
|Figure 1: Multiple discrete brown to black oval nodules attached to hair shaft. These nodules were distributed irregularly along the length of hair shaft|
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|Figure 2: (a) 10% potassium hydroxide (KOH) examination of black colored nodule shows a concretion forming a collar around hair shaft. Concretion was made up of fi lamentous hyphae, held together in a mass by cement like substance. Spores are seen at the edges of the nodule (←), (b) KOH mount of crushed nodule shows brown dematiaceous closely septate hyphae (H) with few chlamydospores (Ch). (c) Culture on Sabouraud's dextrose agar shows small, compact, blackish conical colonies with velvety surface. (d) Microscopic examination of the colonies showed round, dark brown, globus ascus (→) with ascospores|
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|Figure 3: (a) Potassium hydroxide mount of brown colored nodule showing nondematiaceous, loosely arranged septate hyphae with arthroconidia and blastoconidia. (b) Culture on Sabouraud's dextrose agar showing white to cream colored, wrinkled, velvety, dull colonies with a mycelial fringe surrounding the hair shaft. (c) Lactophenol cotton blue mount from the fungal colonies showing multiple hyaline septate hyphae and arthrospores confi rming Trichosporon sp.|
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| Discussion|| |
Piedra, meaning stone in Spanish, is an asymptomatic fungal infection of the hair shaft, resulting in the formation of nodules on the infected hair.  White piedra was described by Beigel (1885) while Magalhaes, a Brazilian investigator, revealed the existence of black piedra, in 1901. Initially, there was much confusion between both types of piedra. Subsequently, in 1911, Horta (Brazil) identified the differentiating features of black piedra and white piedra. 
Occurrence of piedra may be influenced by climatic conditions. Both black-and-white piedra occur predominantly in humid tropical and semi-tropical areas (Africa, South America, and Asia). ,,,, However, white piedra has been reported from temperate climatic areas like Europe, USA and Japan as well. Common sources of infection in both types are stagnant water and soil. Trichosporosis has also been found in vegetable matter, some plants and bird droppings and occasionally in wild mammals. Sexual transmission has been reported in both types of piedra.  Factors such as poor hygiene, long hair, excessive use of hair oil, cultural practices such as tying of veil, especially when done on wet hair may contribute to the infection.
The characteristics of black-and-white piedra are described in [Table 1]. Trichorrhexis nodosa, monilethrix, nits (pediculosis capitis) are the most common differential diagnosis of piedra.
Piedra is best treated by shaving or clipping the hair, but this may not be considered cosmetically or socially acceptable, particularly by women. Topical antifungal azole lotions/shampoos are effective. Oral antifungals such as terbinafine and itraconazole have been used successfully in cases resistant to topical medication. , Patients should be counseled regarding good hygiene, avoidance of use of shared combs and clips, discarding or disinfecting underclothes (in genital piedra) in order to prevent recurrence.
Apart from piedra, Trichosporon sp. can cause onychomycosis and skin infections mimicking eczema. A case has been described with white piedra spores packed inside empty nits of pediculus.  Trichosporon sp. are occasionally a part of gastrointestinal microbiological flora and can transiently colonize the respiratory tract and skin. In immunocompromised patients and patients with hematological malignancies, Trichosporon sp. especially Trichosporon asahii can cause disseminated infection with purpuric skin lesions.  Systemic manifestations include pneumonia, endocarditis, brain abscess, and meningitis. The ability of Trichosporon to form biofilms on implanted devices, presence of glucuronoxylomannan in their cell walls and ability to produce proteases and lipases are possible virulence factors and may account for progress of invasive trichosporonosis. Identification of species of Trichosporon is done on the basis of morphological characteristics of colonies and biochemical tests. Molecular methods of species identification include sequence analysis of the ribosomal DNA intergenic spacer 1 region.
Mixed piedra, a very rare condition is characterized clinically by presence of spangled appearance of hair due to presence of both white and dark colored nodules.  KOH mount and culture show characteristic findings of both P. hortae and Trichosporon sp. Our patient did not show the characteristic spangled appearance. Instead, this patient showed brownish to blackish nodules, which had led to a misdiagnosis of black piedra alone. Hence, it is important to remember that white piedra can also present as brownish nodules. In such cases, it is important to confirm the diagnosis of type of piedra with a mycological examination and culture characteristics. Furthermore, our patient had pediculosis capitis, which was confirmed by presence of nits. However, the possibility of the empty nits packed with the spores of piedra also has to be rarely considered. This case is only the third reported case of mixed piedra in literature.
| Acknowledgments|| |
Dr. Autar Miskeen, Clinical Microbiologist, Central Clinical Microbiology Laboratory.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]