White Piedra in a Mother and Daughter

Case Report

Anupama S Roshan, C Janaki, B Parveen

Department of Dermatology, Madras Medical College, Chennai, India
Address for correspondence:
Dr. Anupama S. Roshan,
Plot No 21, ABC Avenue,
Kaladipet Market lane,
Chennai-19, Tamil Nadu,
India.
Email: dranupamaroshan@
yahoo.co.in

Abstract
White Piedra is a superficial fungal infection of the hair caused by Trichosporon asahii. It
is also known as trichomycosis nodosa or trichomycosis nodularis. We report two cases of
White Piedra in a mother and her daughter for the rarity of such occurrence.
Key words: Topical terbinafine 1%, Trichosporon spp, White Piedra
DOI: 10.4103/0974-7753.58559

Introduction

hite Piedra is an unusual asymptomatic superficial

fungal infection of the hair, characterized by the
presence of numerous, discrete, soft, asymptomatic nodules
loosely attached to the infected hair shafts. It may occur on
the scalp, eyebrows, eyelashes, beard, axilla or in the groin.
Compared with Black Piedra, which almost always occurs
on the scalp hair, White Piedra less commonly affects the
scalp hair and is more common on other hairy sites of
the body. It is caused by a yeast-like fungus, Trichosporon
beigelii, now known as T. asahii,[1] first described by Beigel in
1865. This is more common in temperate climates and has
been reported in Europe and North and South America.
Although it has been reported from many parts of Asia,
it is less common in the tropics. Successful treatment of
White Piedra has been achieved with clipping of affected
hair or tonsuring and use of topical antifungal agents.
Case Report

A 45-year-old lady presented with asymptomatic whitish

nodules in the scalp hair for the past 3 years along with
breakage of the hair shafts [Figure 1]. Her 20-year-old
daughter also had similar complaints for the past 6 months.
Both of them had the habit of tying their wet hair up in a
knot after a hair wash and shared a common comb. There
was no pediculosis in either of them.
Clinical examination revealed whitish to cream-colored,
easily detachable nodules of size 1-1.5mm present over
the shaft of almost all the scalp hairs. The nodules were
seen as encircling the hair shaft completely. Scalp skin and
other hairy areas were normal.
140

Hematological and biochemical investigations were

within normal limits. Test for human immunodeficiency
virus infection was negative. Potassium hydroxide
(KOH 10%) wet mount of the affected hairs showed
septate hyaline hyphae arranged perpendicular to the
hair shaft. Arthrospores and blastospores were seen
[Figure 2]. Culture in Sabourauds dextrose agar (without
cycloheximide) grew yeast-like creamy-white colonies
after 48 h of incubation [Figure 3]. Later, the colonies
became wrinkled, convoluted and had a heaped-up
center. The colonies were creamy white on the reverse.
Lactophenol Cotton Blue mount showed septate hyphae,
arthroconidia and budding blastoconidia [Figure 4]. Thus,
the cultural characteristics confirmed Trichosporon spp.
although speciation was not possible. Both the patients
were advised to keep the hair dry and were treated with
topical application of 1 in 2,000 mercuric perchloride for
3 months along with trimming of the hair regularly. They
were also advised topical terbinafine (1%) twice daily for
the next 3 months, with total resolution of the nodules.
Both the mother and the daughter were followed for the
next 6 months, during which time there was no relapse.
Discussion

Human White Piedra may affect hairs of the scalp, axilla

or crural areas. White Piedra of the scalp occurs with a low
incidence in tropical and subtropical countries.[2,3] People of
all age groups are affected, with a higher incidence in young
women. It is characterized by soft white nodules similar to
nits but can be easily pulled off, unlike nits. The nodules
may be white, pale green or yellow and are composed of
compact fungal elements. The hairs are not invaded but they
may break if the fungi have been there for long period, as
International Journal of Trichology / Jul-Dec 2009 / Vol-1 / Issue-2

Roshan, et al.: White piedra

Figure 1: Whitish to cream-colored easily detachable nodules of size

1-1.5mm present over the shaft of almost all the scalp hair

Figure 2: KOH 10% wet mount of the affected hairs showed septate
hyaline hyphae arranged perpendicular to the hair shaft

Figure 3: Culture (in agar without cycloheximide) grew yeast-like

creamy white colonies after 48 h of incubation

Figure 4: Lactophenol cotton blue mount showing septate hyphae,

arthroconidia and budding blastoconidia

has happened in our cases. Occasionally, the adjoining skin

can get infected, especially in areas like the groin, causing
intertrigo, which is considered as a form of cutaneous
trichosporosis.[4]

also been suggested.[6] Although it relapses frequently,

removal of the affected hair is usually curative, with few
recurrences.

White Piedra is caused by several Trichosporon species,

like T. asahii, T. cutaneum, T. inkin, T. ovoides and T. mucoides.
Members of this species have multilamellar cell walls in
common and contain more or less developed dolipore
septa with or without vesicular or tubular parenthesomes.[5]
Budding cells are abundant in primary cultures but hyphae
predominate after repeated transfer.

References

Our patient gave a typical history of tying up wet hair and

also sharing of comb with her daughter, enabling disease
transmission. The disorder can be controlled by shaving
and by local application of 5% ammoniated mercury
ointment, topical 2% miconazole, 2% ketoconazole or
1% terbinafine four times a day for a period of 2 weeks
or till remissions occur.[1] Oral itraconazole therapy has
International Journal of Trichology / Jul-Dec 2009 / Vol-1 / Issue-2

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Source of Support: Nil, Conflict of Interest: None declared.
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