History

Fact Explanation
Nodules in hair sharft Black piedra is a peculiar hair infection caused by the the superficial mycoses called Piedraia hortae.[4]. It is an asymptomatic fungal infection of the hair shaft, resulting in the formation of nodules of different hardness on the infected hair. Usually hosts do not produce any immune-reactive response, so that they are called as superficial mycoses.[2]. It is characterized by the formation of firmly attached, black and hard nodules around the hair shaft.[1].
Hair brakage Black piedra mostly affects scalp hair. The affected hair breaking in bits at the level of the nodules can be seen.[2].
History of living in a tropical climates Black piedra is normally distributed in tropical climates,although it has occasionally been reported in other parts of the world. It is commonly found in tropical countries such as South America and South East Asia .[2].
History of application of plant oils on wet hair In certain tropical countries application of plant oils on wet hair is implicated as a favorable factor for piedra infection. It is further favored by the high humidity.[2].
Metallic sound on combing Piedra itself means "stones" in spanish. Black piedra mostly affects scalp hair with darkly pigmented stony hard nodules firmly attached around the hair shaft. This is able to create a metallic sound on combing.[2].
Difficulty in combing hair Patients are often complained difficulty in combing hair due to the nodules in their hair shaft.[3].
History of poor hygiene and history of sexual activity with a infected person Factors such as poor hygiene, long hair, excessive use of hair oil, may contribute to the infection. Sexual transmission found to be occurred in both black and white piedra.[3].
History of long term covering head with veils Cultural practices such as tying of veil, specially when done on wet hair , also found to be a contributory factor for infection.[3].
References
  1. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.58552
  2. SAXENA SEEMA, UNIYAL VEENA, BHATT R.P.. Inhibitory effect of essential oils against Trichosporon ovoides causing Piedra Hair Infection. Braz. J. Microbiol. [online] 2012 December, 43(4):1347-1354 [viewed 13 September 2014] Available from: doi:10.1590/S1517-83822012000400016
  3. POOJARY SHITALAMIN, NAGPUR NIRANJANG, KHATU SWAPNAS. Nodules on the hair: A rare case of mixed piedra. Int J Trichol [online] 2013 December [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.130421
  4. WALSH TJ, DIXON DM, BARON S. Spectrum of Mycoses [online] 1996 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21413276

Examination

Fact Explanation
Nodules located to a specific areas Black Piedra is characterized by the presence of firm black, hard, gritty nodules which are actually a mass of fungus cells on the hair shaft. Those nodules are commonly found in scalp, but not limited to that. If may also found in hairs of the beard, moustache and pubic hair with the fungal activity limited to the cuticle.[1].
References
  1. SAXENA SEEMA, UNIYAL VEENA, BHATT R.P.. Inhibitory effect of essential oils against Trichosporon ovoides causing Piedra Hair Infection. Braz. J. Microbiol. [online] 2012 December, 43(4):1347-1354 [viewed 13 September 2014] Available from: doi:10.1590/S1517-83822012000400016

Differential Diagnoses

Fact Explanation
Head lice infestation (pediculosis) Head lice called Pediculus capitis infestations is a burden problem among most of school children. Infestation with lice is called pediculosis.It involves less than 10 live lice. infestation can be asymptomatic as well as can be symptomatic. Sensitized to antigenic components of louse saliva will produce itching. It releases saliva while feeding.In case of first infestation,sensitization may take four to six weeks. Neglected heavy infection may cause secondary infections and leads to excoriated scalp.Head lice are thought to be spread mainly through direct hair to hair contact.[1].
Tinea capitis A dermatophte infection caused by trichophyton and microsporum in scalp hair.[3]. It occurs most commonly in children because most of the times adults hair is resistant to that infection. If childhood infection left untreated mostly it is clears up at puberty. Infection causes circular bald patches with scales and broken hairs.The hairs may break either level with the scalp. It will form black dots with fungi invading the hair (endothrix). Or it may break one to two mm from the surface, in which case the fungi surround the hair (ectothrix). Due to inflammatory response bald patches may slightly erythematous and scaly. The severe form of disease is called "'Kerion''.[2].
Trichomycoses Trichomycoses are diseases of the hair caused by fungi.The common agents causing hair infections are dermatophytes, Malassezia species and those causing piedra. Infection cause hair loss causing cosmetic problems to the patient. Further more fungi can induce severe inflammation, which may disable the persons. It can cause recurrent infection and development of chronicity.There may be infection of the siblings and schoolmates in residential schools.[4].
Monilethrix Monilethrix is a rare hereditary hair shaft disorder usually inherited as an autosomal dominant manner.It may rarely present as autosomal recessive. Monilethrix word is derived from Greek language meaning “The Beaded Hair". The less severe type of monilethrix causes normal hair at birth, but develop hair shaft defects after a few months.Keratin gene mutations lead to severe forms involving body hair including the eyebrows and the eyelashes. Nails may show Koilonychia. "Regularly bended ribbon sign" in Monilethrix is useful to differentiate it from pseudomonilethrix.[5].
Trichorrhexis nodosa Trichorrhexis nodosa is a hair shaft disorder.Congenital trichorrhexis nodosa is a congenital hair shaft anomaly inherited as an autosomal dominant manner. Acquired disease is caused by weathering from physical or chemical causes.The more common acquired form results from repeated trauma to the hair shaft. Disease is characterized by easy breakability of hair. Microscopically it will show nodes on the hair shaft.[6].
References
  1. Head lice infestations: A clinical update Paediatr Child Health [online] 2004 Nov, 9(9):647-651 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724133
  2. BITAR A. Superficial Mycoses Can Fam Physician [online] 1973 Sep, 19(9):65-68 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2371115
  3. DIAS MF, QUARESMA-SANTOS MV, BERNARDES-FILHO F, AMORIM AG, SCHECHTMAN RC, AZULAY DR. Update on therapy for superficial mycoses: review article part I An Bras Dermatol [online] 2013, 88(5):764-774 [viewed 14 September 2014] Available from: doi:10.1590/abd1806-4841.20131996
  4. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 14 September 2014] Available from: doi:10.4103/0974-7753.58552
  5. AVHAD G, GHUGE P. Monilethrix Int J Trichology [online] 2013, 5(4):224-225 [viewed 14 September 2014] Available from: doi:10.4103/0974-7753.130423
  6. MARTIN AM, SUGATHAN P. Localised Acquired Trichorrhexis Nodosa of the Scalp Hair Induced by a Specific Comb and Combing Habit - A Report of Three Cases Int J Trichology [online] 2011, 3(1):34-37 [viewed 14 September 2014] Available from: doi:10.4103/0974-7753.82138

Investigations - for Diagnosis

Fact Explanation
Direct microscopic examination Disease is mainly diagnosed by clinical history and examination. Other method is direct microscopy using KOH solution.Wet mount of the nodules in KOH is confirmatory. There we can see organized brown spores in black piedra invading the hair.Matured nodules will show asci that means sexual spores containing eight ascopore. Each one shows a small flagellum at their tip, which is better seen when the ascus is ruptured.[1].
Culture Sabouraud's dextrose agar is used for culture.Culture from black colored nodule on the Sabouraud's dextrose agar at room temperature will grow small, compact, blackish conical colonies with velvety surface . The reverse side of the colonies also reveals black colonies. When looking at those colonies with microscopy it will show round, dark brown, globus ascus that confirmatory for Piedraia hortae species.[2].
References
  1. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.58552
  2. POOJARY SHITALAMIN, NAGPUR NIRANJANG, KHATU SWAPNAS. Nodules on the hair: A rare case of mixed piedra. Int J Trichol [online] 2013 December [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.130421

Management - General Measures

Fact Explanation
Avoid moisture, Black piedra tends to grow in moist humidified areas.So that avoidance of moisture is one of the treatment option.[1].
Clipping and shaving the hairs /trichotomy Clipping and shaving of the affected hair is another established treatment . But most women do not prefer that due to cosmetic reasons. [1],[2].The general rule is to carry out trichotomy on affected hair [3].
Remove using fine comb Removal using a fine comb is recommended in cases involving women.[3].
Maintain good hygiene 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 recurrences.[2].
References
  1. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.58552
  2. POOJARY SHITALAMIN, NAGPUR NIRANJANG, KHATU SWAPNAS. Nodules on the hair: A rare case of mixed piedra. Int J Trichol [online] 2013 December [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.130421
  3. DIAS MF, QUARESMA-SANTOS MV, BERNARDES-FILHO F, AMORIM AG, SCHECHTMAN RC, AZULAY DR. Update on therapy for superficial mycoses: review article part I An Bras Dermatol [online] 2013, 88(5):764-774 [viewed 14 September 2014] Available from: doi:10.1590/abd1806-4841.20131996

Management - Specific Treatments

Fact Explanation
Application of terbinafine, tolnaftate and azoles Topical application of high concentration of terbinafine, tolnaftate, azoles and 1 in 2,000 mercury bichloride solution can be carried out.[1]. And topical application of antifungal azole lotions/shampoos are also found to be effective.[1].
Oral terbinafine and itraconazole In case of resistance to tropical application of anti fungal creams, can change the treatment in to oral terbinafine and itraconazole which has proven to have successful outcomes.[1].
Use sublimate solution Use sublimate solution 1/1000 or even 1/2000 in 60% alcohol can be carried out.Treatment involves cologne, using the same amount of mercury bichloride, 0.3g of sublimate solution for 300ml of cologne, or 600ml, if the 1/2000 proportion is chosen.[2].
Mercury bichloride or 2% formaldehyde Mercury bichloride 1/1000 or 2% formaldehyde reduce the risk of cutting hair by producing good results.But infection usually recur after treatment.[2].
References
  1. POOJARY SHITALAMIN, NAGPUR NIRANJANG, KHATU SWAPNAS. Nodules on the hair: A rare case of mixed piedra. Int J Trichol [online] 2013 December [viewed 13 September 2014] Available from: doi:10.4103/0974-7753.130421
  2. DIAS MF, QUARESMA-SANTOS MV, BERNARDES-FILHO F, AMORIM AG, SCHECHTMAN RC, AZULAY DR. Update on therapy for superficial mycoses: review article part I An Bras Dermatol [online] 2013, 88(5):764-774 [viewed 14 September 2014] Available from: doi:10.1590/abd1806-4841.20131996