Introduction
What is piedra?
Piedra is a fungal infection of the hair, characterized by the deposition of small black or white
nodules along the hair shaft. These look like small stones, hence the name piedra, meaning
‘stone’ in Spanish.
Piedra is also known as Trichomycosis nodosa or Trichomycosis nodularis.
There are two types: black piedra and white piedra, caused by different fungi and named because
of the colour of fungal deposits they cause on the hair shaft.
Etiology
The exact mechanism by which piedra is contracted is not well understood, however, it appears
that anyone who is exposed to a causative fungus is at risk.
Piedra is caused by infection of the hair with certain fungi.
*Black piedra is caused by the fungus Piedraia hortae.
*White piedra is usually caused by Trichosporon spp., mainly T. cutaneum, T. ovoide, and T.
inkin.
Pathogenesis
Infection starts just beneath the hair cuticle following damage, the fungal organism may grow
inward & through the shaft to form nodular swelling spaced irregularly along the axis.
Hair is weakened at those points hence it easily breaks.
Growth of the fungal infection occurs around the hair shaft & consists of mycelia that rapidly
fragment into arthrospores( fungal spores formed through fragmentation).
Transmission
Black piedra has a different method of transmission to white piedra.
For black piedra [Piedraia hortae]
The soil seems to be the primary source of infection in black piedra, although it has been traced
in stagnant water & crops.
P.hortae can produce sexual spores in its parasitic phase, which is a special feature of the fungus.
White piedraIt is asymptomatic and manifests as small yellow concretions on the scalp. The
spread of piedra directly from person to person is uncommon. However, it is possible to transmit
the infection through the genital region through sexual activity. After a person is exposed, the
fungus needs the right conditions to survive and colonize human hair.
Clinical symptoms
Patients with piedra have small, round, or ovoid nodules of fungus attached to or encircling the
hair shafts. These can range in size from <1 millimeter (mm) to a few mm in diameter. Piedra
typically occurs on scalp hair but can also be found in facial, armpit, and pubic hair.
Black piedra:
● Brown to black coloured nodules
● Very firm and gritty to touch
● Well-attached to the hair shaft.
White piedra:
● White/off-white to light-brown coloured nodules
● Softer texture
● Easier to detach from the hair shaft.
Piedra is otherwise largely asymptomatic and patients do not typically report any pain or itch. A
clinical clue for doctors to consider piedra is a negative ‘hair pull’ test. This suggests the
problem is not at the root of the hair, but somewhere along the shaft.
Diagnosis
Diagnosis of both types of piedra can be made by microscopic examination of the nodules on the
hair shaft. The hair should be plucked and prepared with 10% potassium hydroxide solution and
a fungal stain such as black.
Trichoscopy — similar to dermoscopy, trichoscopy is the process of looking at hair under
magnification. It is useful for excluding differential diagnoses such as head lice. Fungal culture
— the gold standard for diagnosis. Strand(s) of hair are sent for culture and staining to visualize
characteristic hyphae and/or spores.
Treatment
Both black and white piedra can be treated by shaving the hair so as to remove the nodules.
Black piedra
• Antifungal medications such as topical or oral ketoconazole are commonly prescribed as well
as a variety of keratolytic agents, but shaving the hair remains the best approach to eliminate the
fungus.
• Good personal hygiene and keeping the area dry and clean can prevent recurrence.
White piedra
• can be treated with a variety of topical antifungal agents, including topical imidazoles,
ciclopirox, 2% selenium sulfide lotion, etc
• shaving of the affected area.
• Good hygiene.
• White piedra of the genital area that is recurrent can be treated with a combination of shaving
and topical antifungals, and ensuring disinfection of undergarments, bedding, and towels.
Prevention of piedra
Personal hygiene — regular washing of hairy body sites.
Consider keeping scalp hair short, and regular shaving/waxing of body or facial hair.
Avoid potential sources of the causative fungi. This includes hair brushes and pillows that were
previously used during infection, to prevent reinfection.
As person-to-person spread is rare, there are currently no recommendations for prophylactic
treatment of close contacts of those with the condition.
Reference
● El Attar Y, Atef Shams Eldeen M, Wahid RM, Alakad R. Efficacy of topical vs combined
oral and topical aPiegals in white piedra of the scalp. J Cosmet Dermatol.
2021;20(6):1900–1905. doi: 10.1111/jocd.13769.
● Schwartz RA. Superficial fungal infections. Lancet. 2004;364(9440):1173–1182. doi:
10.1016/S0140-6736(04)17107-9.
● Sharma P, Nassereddin A, Sonthalia S. Black Piedra. In: StatPearls. Treasure Island (FL):
StatPearls Publishing; February 13, 2023.
● Black piedra- state pearls- NCBI Bookshelf.
● Fungal infection in hair, Dr. Vishal kulkarmi [MBBs MD Microbiology].
