History

Fact Explanation
Nodules in hair shaft White piedra is an asymptomatic superficial fungal infection caused by yeast-like fungus called, Trichosporon beigelii, now also known as T. asahii. Disease can be also caused several other trichosporon species, such as T. cutaneum, T. inkin, T. ovoides and T. mucoides.Disease is characterized by the presence of discrete, soft, asymptomatic nodules which is loosely attach to the hair shafts. It is less commonly affect the scalp hair and commonly seen in other hairy sites of the body.[1].
History of living in a temperature climate Disease commonly found in temperature climates. It is reported in people who live in Europe and North and South America. Even it has been reported in Asia, it is less common in tropics.[1].
History of being young females Even though the people in all age groups are affected, the higher incidence found in young women.[1].
History of tying of veil Tying of veil in some cultural practices may contribute to the infection. Occurs specially when it is done on wet hair.[3].
History of application of plant oils on wet hair It act as a main contributory factor for piedra infection specially in the tropical countries. It is further supported by the high humidity.[2].
History of poor hygiene and sexual activity with infected patient. Factors such as poor hygiene, long hair, excessive use of hair oil found to be act as risk factors for the disease. And also sexual transmission is reported in both black and white piedra.[3].Sharing of the same comb and towel in a family also found to be a causative factor for spreading of the disease.[5].
Braking of hair Braking of hair can be seen in long standing disease.[1]. Hair breaking in bits at the level of the nodules can be identified.[2]. Growth of the fungus both with in and outside the hair shaft , leads to weaken hair shaft that ultimately break off.[3].
Hair loss Infection causes progressive weakness of the hair shaft, that leading to hair fall.[4].
Endocarditis and pericarditis T. inkin one of the causative species of white piedra can occasionally cause systemic infection resulting endocarditis and pericarditis.[4].
References
  1. ROSHAN AS, JANAKI C, PARVEEN B. White Piedra in a Mother and Daughter Int J Trichology [online] 2009, 1(2):140-141 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58559
  2. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58552
  3. KHATU SS, POOJARY SA, NAGPUR NG. Nodules on the Hair: A Rare Case of Mixed Piedra Int J Trichology [online] 2013, 5(4):220-223 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.130421
  4. TENDOLKAR UMA, SHINDE ALKA, BAVEJA SUJATA, DHURAT RACHITA, PHISKE MEGHANA. Trichosporon inkin and Trichosporon mucoides as unusual causes of white piedra of scalp hair. Indian J Dermatol Venereol Leprol [online] 2014 December [viewed 19 September 2014] Available from: doi:10.4103/0378-6323.136896
  5. KRIPLANI DIMPLE, PATEL BHARTI, VISWANATH VISHALAKSHI, MISKEEN AUTARKISHEN, TORSEKAR RAGHUNANDANGOVIND. White piedra of scalp hair by Trichosporon inkin. Indian J Dermatol Venereol Leprol [online] 2011 December [viewed 19 September 2014] Available from: doi:10.4103/0378-6323.84065

Examination

Fact Explanation
Easily detachable nodules in hair Disease characterized by soft creamy white gelatinous nodules loosely attached to the hair shaft which can be easily pulled off.The nodules may be white, pale green or yellow. They are composed of compact fungal elements.[1],[2].
Nodules located to specific areas of the body Unlike black piedra, white piedra less commonly found in scalp hair. The nodules commonly found in other hairy areas of the body such as eyebrows, eyelashes, beard, axilla or in the groin.[1].
References
  1. ROSHAN AS, JANAKI C, PARVEEN B. White Piedra in a Mother and Daughter Int J Trichology [online] 2009, 1(2):140-141 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58559
  2. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58552

Differential Diagnoses

Fact Explanation
Pediculosis It is a most common problem among school and preschool children. Pediculosis (head lice) is caused by Pediculus capitis. However three types of lice are found in human body including head lice, body lice and pubic lice. They have property of blood-sucking.When feeding or moving in the skin, It can cause skin irritation and itching at the site of blood-sucking. Head lice,which is an obligatory parasite, sucks human blood but they do not transmit any disease to human. Lice are brown or gray in color and it lays about 3-4 eggs on the hair specially around the ears and behind the neck every night. It can spread by direct contact of infested person.[1],[2].
Monilethrix Monilethrix word is derived from Greek language meaning “The Beaded Hair.” It is inherited in autosomal dominan manner bur rarely can inherited in autosomal recessive manner. Mutation in hHb1usually leads to less severe type of monilethrix. It will cause normal hair at birth, but develop hair shaft defects after a few months. Keratin gene mutations (hHb3 and hHb6) lead to severe form of disease. it will involve hair including the eyebrows and the eyelashes.Nails may show Koilonychia. Monilethrix can be differentiate by pseudomonilethrix from its “regularly bended ribbon sign” .[3].
Trichorrhexis nodosa Trichorrhexis nodosa is a hair shaft disorder.It will leads to easy breakability of hair.Microscopic examination will show nodes on the hair shaft. Disease can be congenital or acquired.Repeated trauma to the hair shaft is considered as main cause of acquired disease. Congenital form is inherited in autosomal dominant manner.[4].
Trichomycosis It is a diseases of the hair caused by fungi.The causative fungi affecting the follicular units are mostly dermatophytes, agents causing piedra and Malassezia. From them dermatophytes and piedra directly invade the hair.It causes cosmetic problem due to loss of hair in women.The antigens of these fungi can induce severe inflammation. It may leads to recurrent infections and sometimes develop chronicity.[5].
Tinea capitis It causes invasion of the hair follicle and surrounding skin, caused by trichophyton and microsporum. Breaking of hair can occur close to the skin. It can manifest clinically as Non-inflammatory dermatosis caused by the ectothrix fungus or Folliculitis capitis abscedens et suffodiens or Inflammatory dermatosis. In non-inflammatory dermatosis black dots can appear, where the blackish points located in areas of broken hairs. Interconnecting tunnels and abscesses on the scalp can produced in folliculitis capitis abscedens and yellowish crusts in large areas of the scalp is seen in Inflammatory dermatosis. If left untreated it can leads to scarring alopecia.[1].
References
  1. 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 19 September 2014] Available from: doi:10.1590/abd1806-4841.20131996
  2. RIABI HR, ATARODI A. Epidemiological and Clinical Study of Infested Cases with Pediculus capitis and P. corporis in Khorasan-e-Razavi, Iran Iran J Parasitol [online] 2012, 7(1):85-91 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488826
  3. AVHAD G, GHUGE P. Monilethrix Int J Trichology [online] 2013, 5(4):224-225 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.130423
  4. 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 19 September 2014] Available from: doi:10.4103/0974-7753.82138
  5. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58552

Investigations - for Diagnosis

Fact Explanation
KOH mount Usually the disease diagnosed clinically. However the use of wet mount of the nodules in KOH is confirmatory.[1]. Here digesting of hair shaft nodule with 10-15% KOH to visualize hyphae is carried out.[4]. Examination will show grouped hyaline spores of varying sizes invading the hair.[1]. Furthermore it will show nondematiaceous loosely arranged septate hyphae with arthroconidia ranging from 2-4 micrometers and also budding blastoconidia.[2].
Culture Culture of the nodules in Sabouraud's dextrose agar will show characteristic rapid growth of soft creamy and wrinkly sometimes mucoid colonies.[2]. Cerebriform colonies which are lack in marginal zone and often crack the agar at periphery can be identified.[4].
Microscopic examination of culture isolate It will show hyphae, budding cells and arthroconidia. Since the white piedra is caused by several species, it is necessary to carried out physiological tests and genetic analyses to differentiate the species.[2]. Budding cells are found to be abundant in primary cultures ,but hyphae predominate after repeated transfer.[3].
Electron microscopy, molecular and biochemical methods Performed to differentiate species. Electron microscopy usually helps in species identification by recognizing various details like cross-section of the cell wall and septum. RapID Yeast Plus system, API 20C Aux system and Vitek Yeast Biochemical Card are the available biochemical methods. Ribosomal DNA internal transcribed spacer region (ITS), and ribosomal DNA intergenic spacer (IGS) analysis are molecular methods that can be used to identify species.[4].
References
  1. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58552
  2. KHATU SS, POOJARY SA, NAGPUR NG. Nodules on the Hair: A Rare Case of Mixed Piedra Int J Trichology [online] 2013, 5(4):220-223 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.130421
  3. ROSHAN AS, JANAKI C, PARVEEN B. White Piedra in a Mother and Daughter Int J Trichology [online] 2009, 1(2):140-141 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58559
  4. KRIPLANI DIMPLE, PATEL BHARTI, VISWANATH VISHALAKSHI, MISKEEN AUTARKISHEN, TORSEKAR RAGHUNANDANGOVIND. White piedra of scalp hair by Trichosporon inkin. Indian J Dermatol Venereol Leprol [online] 2011 December [viewed 19 September 2014] Available from: doi:10.4103/0378-6323.84065

Management - General Measures

Fact Explanation
Shaving of hair Disease can control by shaving hair. Even though it relapses frequently, removal of the affected hair is usually has few recurrences.[1].But this may not be considered cosmetically or socially acceptable, specially by most of the women.[3].
Avoidance of moisture and hair clipping Avoidance of moisture, clipping of the affected hair is another basic measurements that can be done to control disease.[2].
Maintain good hygiene Patients should be counseled regarding good hygiene. They should asked to avoid the use of shared combs and clips. Furthermore asked them to discard or disinfect undergarments specially in case of genital piedra, in order to prevent disease recurrence.[3].
References
  1. ROSHAN AS, JANAKI C, PARVEEN B. White Piedra in a Mother and Daughter Int J Trichology [online] 2009, 1(2):140-141 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58559
  2. SENTAMILSELVI G, JANAKI C, MURUGUSUNDRAM S. Trichomycoses Int J Trichology [online] 2009, 1(2):100-107 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58552
  3. KHATU SS, POOJARY SA, NAGPUR NG. Nodules on the Hair: A Rare Case of Mixed Piedra Int J Trichology [online] 2013, 5(4):220-223 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.130421

Management - Specific Treatments

Fact Explanation
Tropical application of antifungal craems Miconazole, ketoconazole can be used. [1]. Ketoconazole is broad-spectrum antifungal drug. Both are azoles and they are capable of inhibiting the demethylation of sterol's carbon-14 in fungal wall cells. And also it is capable to inhibit the normal ergosterol biosynthesis ,modifying its biochemical composition thereby inhibition of fungal growt and replication.Both above drugs are indicated in all superficial mycoses.[3].Topical application of 2% miconazole, 2% ketoconazole or 1% terbinafine four times a day for a period of 2 weeks or till remission will give successful outcome.[1]. Itching, burning, stinging and contact dermatitis are the common side effects of topical application of Ketoconazole. [3].
Oral itraconazole It is a synthetic, fungistatic triazole, that inhibits cytochrome P450 enzyme (CYP450) ,thereby interrupting fungal cell growth and division.[3]. Oral itraconazole therapy found to be benificial in white piedra.[1]. It can be used specially in case of resistant to topical medications.[2].This drug is metabolized by the liver and eliminated through the kidneys and found to be best absorbed using after meals. Drug interactions are common and contraindicated in patients with congestive heart failure. common side effects include headache, nausea, abdominal pain, dyspepsia, gastritis, diarrhea ,hepatitis, urticaria, rash, Stevens Johnson syndrome, etc..[3].
5% ammoniated mercury ointment Disease also found to be controlled by local application of 5% ammoniated mercury ointment.[1].
References
  1. ROSHAN AS, JANAKI C, PARVEEN B. White Piedra in a Mother and Daughter Int J Trichology [online] 2009, 1(2):140-141 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.58559
  2. KHATU SS, POOJARY SA, NAGPUR NG. Nodules on the Hair: A Rare Case of Mixed Piedra Int J Trichology [online] 2013, 5(4):220-223 [viewed 19 September 2014] Available from: doi:10.4103/0974-7753.130421
  3. DIAS MF, BERNARDES-FILHO F, QUARESMA-SANTOS MV, AMORIM AG, SCHECHTMAN RC, AZULAY DR. Treatment of superficial mycoses: review - part II An Bras Dermatol [online] 2013, 88(6):937-944 [viewed 19 September 2014] Available from: doi:10.1590/abd1806-4841.20132018