International Journal of Trichology International Journal of Trichology
 Print this page Email this page Small font sizeDefault font sizeIncrease font size
  Home | About IJT | Editorial board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submission | Subscribe | Advertise | Contact us | Login   

 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 3  |  Page : 134-137  

A case of scalp white piedra caused by trichosporon ovoides

Department of Dermatology, Venereology and Leprosy, GMC, Kota, Rajasthan, India

Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. Suresh Kumar Jain
Department of Dermatology, Venereology and Leprosy, GMC, Kota - 324 005, Rajasthan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijt.ijt_19_19

Rights and Permissions

White piedra also known as trichomycosis nodularis or trichomycosis nodosa is a superficial fungal infection of the hair shaft caused by Trichosporon asahii. We are reporting a case of white piedra in a female for the rarity of such occurrence.

Keywords: Trichomycosis nodularis or trichomycosis nodosa, Trichosporon sp., white piedra

How to cite this article:
Singh A, Nyati A, Mohta A, Kushwaha RK, Jain SK. A case of scalp white piedra caused by trichosporon ovoides. Int J Trichol 2019;11:134-7

How to cite this URL:
Singh A, Nyati A, Mohta A, Kushwaha RK, Jain SK. A case of scalp white piedra caused by trichosporon ovoides. Int J Trichol [serial online] 2019 [cited 2022 Jun 29];11:134-7. Available from: https://www.ijtrichology.com/text.asp?2019/11/3/134/259984

   Introduction Top

White piedra is a superficial fungal infection of the hair shaft, caused by Trichosporon beigelii. It is also known as tinea nodosa, trichosporonosis nodosa, and trichomycosis nodularis.[1] Clinically, characterized by the presence of asymptomatic numerous, discrete, soft nodules loosely attached to the infected hair shafts, producing a sensation of grittiness. They are microscopic, with about 0.5 mm in diameter. Coalescence results in a sleeve-like mass indistinguishable from trichomycosis axillaris.[2] Commonly involved sites are distal portions of facial, beard, moustache and pubic hairs, with the scalp being rarely involved.[1] In contrast, black piedra almost always occurs on the scalp hair.

   Case Report Top

A 32-year-old Muslim female presented in our skin outdoor for the evaluation of asymptomatic palpable nodules along the scalp hairs since 3 months. She had been using henna mehndi for 2 years and had a history of tying wet hairs after washing. Other hairy parts of the body and scalp skin were normal. There was no pediculosis. There was no history of similar involvement in family members.

On clinical examination, scalp hairs were normal-looking without evidence of sparseness. However, individual hair showed barely visible but well-palpable whitish to cream-colored, easily detachable nodules of size 1–1.5 mm present over the shaft of almost all the scalp hairs, distributed at irregular intervals and not easily movable along the hair shaft [Figure 1].
Figure 1: Dermoscopic view of affected hair showing whitish to cream-colored nodules adherent to scalp hair

Click here to view

Hair pull test result was negative. Wood's lamp examination of the affected and uninvolved hairs did not show any fluorescence. Potassium hydroxide 10% wet mount of the affected hair revealed clusters of blastoconidia were present intermittently along the hair shaft [Figure 2].
Figure 2: Potassium hydroxide 10% wet mount of the affected hair revealing clusters of blastoconidia

Click here to view

Growth on Sabouraud agar at 37°C and 22°C showed soft whitish to cream-colored wrinkled colonies at the end of 1 week [Figure 3]a.
Figure 3: (a) Creamy white wrinkled cerebriform colony on Sabouraud dextrose agar, (b) Fungal arthrospore seen on lactophenol cotton blue (×400), (c) Pink color on urease test indicating a positive reaction

Click here to view

The lactophenol cotton blue mount of the isolate showed pleomorphic yeast cells and septate hyphae fragmenting to form rectangular arthrospores and blastoconidia [Figure 3]b. Therefore, on the basis of macroscopic findings, microscopic findings, and urease test positivity [Figure 3]c identity of T. beigelii complex had been confirmed.

The patient was treated with topical 2% ketoconazole shampoo twice a week and oral itraconazole 100 mg once daily along with trimming of the hair regularly, resulting in a decrease in the palpability of nodules (concretions) and fragility of scalp hairs at the end of 2 months, with complete resolution at the end of 3 months. The patient was followed for the next 6 months, during which time there was no relapse.

   Discussion Top

White piedra belongs to family Cryptococcaceae, class Basidiomycetes and is an unusual infection of worldwide distribution usually seen in temperate and topical areas including Europe, Asia, Japan, and southern United States.[1],[2]

It is caused by a T. beigelii, now known as Trichosporon asahii,[3] yeast-like fungus, first described by Beigel in 1865 and the first case in India was reported by Basuet al. in 1970.[2]

All age groups are affected, with a higher incidence in young women.[4] Age and sex incidence varies from country to country, depending on the prevalent hairdressing fashions and social customs.[2] Whether the custom of covering hairs is a contributory factor that needs to be studied. The higher incidence of scalp white piedra is observed in Muslim females; contributing factor being the custom of using a veil, leading to higher humidity, and limited sunlight exposure. Only a handful of cases of white piedra have been reported in the past [Table 1].
Table 1: Various reported cases of white piedra

Click here to view

Gueho has subdivided T. beigelii into six species, pathogenic to humans.[2],[5] These include Trichosporon ovoides, Trichosporon inkin, Trichosporon ashii, Trichosporon mucoides, Trichosporon asteroides, and Trichosporon cutaneum. Carbohydrate assimilation test is done for species identification. T. ovoides and T. inkin are usually associated with white piedra. T. ovoides causes white piedra of the scalp, while T. inkin leads to pubic piedra. T. asteroides and T. cutaneum are isolated less frequently in superficial lesions and are probably contaminants.[2] T. ashii causes hematogenously disseminated infections, while T. mucoides usually causes central nervous system involvement in immunocompromised patients. Therefore, species identification is an important aspect.

The differential diagnosis includes pediculosis capitis, trichomycosis axillaris (trichobacteriosis), monilethrix, trichorrhexis nodosa, and peripilar keratin cast [Table 2].[2]
Table 2: Differential diagnosis of white piedra

Click here to view

Shaving of affected hair is the most effective and curative remedy but generally not acceptable in females.[1] Topical antifungals commonly used are 2% ketoconazole, ciclopirox olamine shampoo, 2% selenium sulfide, 6% precipitated sulfur in petrolatum, zinc pyrithione and amphotericin B lotion, or 1% terbinafine four times a day for 2 weeks or till remissions occurs.[3] Oral agents include ketoconazole and amphotericin B.[6] Recent reports show that itraconazole is also effective in the treatment of white piedra, although it relapses frequently.[4] Therefore, oral azole antifungal agents eliminate the scalp carriage or infection, whereas topical antifungal eliminates the hair shaft concretions without the need for shaving.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hay RJ, Moore MK. Mycology. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's textbook of dermatology 7th edn. London: Blackwell Science; 2004. p. 31.16-8.  Back to cited text no. 1
Basu N, Sanyal M, Banerjee AK, Thammayya A. White piedra in India. Ind J Dermatol Venereol Leprol. 1970;36:154-5.7.  Back to cited text no. 2
Schwartz RA, Altman R. Piedra. eMedicine Specialties. Available from: http://emedicine.medscape.com/article/1092330-overview. [Last accessed on 2019 Apr 14].  Back to cited text no. 3
Khandpur S, Reddy BS. Itraconazole therapy for white piedra affecting scalp hair. J Am Acad Dermatol 2002;47:415-8.  Back to cited text no. 4
Pontes ZB, Ramos AL, Lima Ede O, Guerra Mde F, Oliveira NM, Santos JP, et al. Clinical and mycological study of scalp white piedra in the state of Paraíba, Brazil. Mem Inst Oswaldo Cruz 2002;97:747-50.  Back to cited text no. 5
James WD, Berger TG, Elston DM. Diseases resulting from fungi and yeast. Andrews Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa: W.B. Saunders; 2006. p. 312-3.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

This article has been cited by
1 White Piedra: An Uncommon Superficial Fungal Infection of Hair
Vishal Gaurav, Chander Grover, Shukla Das, Gargi Rai
Skin Appendage Disorders. 2022; 8(1): 34
[Pubmed] | [DOI]
2 White Piedra, a Rare Superficial Mycosis: an Update
Arturo Robles-Tenorio, Kenia Yolanda Lepe-Moreno, Jorge Mayorga-Rodríguez
Current Fungal Infection Reports. 2020; 14(3): 197
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Case Report
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded53    
    Comments [Add]    
    Cited by others 2    

Recommend this journal