Contains concise description about white and black piedra, their diagnosis and treatment

1. Fungal Infection in Hair
Dr Vishal Kulkarni
MBBS MD (Microbiology)

2. Introduction
Hair is one of the defining characters of
humans.
Fungi that causes infection of hair
- Trichosporon spp.
- Piedra Hortae
- Dermatophytes.

3. Piedra-
• Superficial infection of hair shaft.
• Often asymptomatic
• Piedra (spanish)- stone
• Two types-
• White piedra (Trichosporon spp.)
• Black piedra ( Piedra hortae)

4. White Piedra
 Caused by yeast-like fungal species of genus
Trichosporon.
 Present as branched hyphae & arthrospores both
within and around hair shaft.
 Trichomycosis nodularis OR
Trichosporonosis nodosa.
 Systemic infection- Trichosporonosis.
 Was first described by Biegel in 1865.

5. Mycology-
Family- Cryptococcaceae
Class- Basidiomycetes.
White piedra 1.Head- Trichosporon
ovoides
2.Pubis- Trichosporon inkin

6.  Epidemology-
 Inhabits in soil & human skin.
 Has also been described in horses, monkeys,
dogs etc.
 Affects temperate & tropical areas including
Eastern Europe, Asia, South America.
 More common in Black people.
 Incidence varies according to hair styling
fashion, social customs, hygienic conditions,
humidity.

8.  Pathogenesis & Pathology-
 Infection starts just beneath cuticle following
damage.
 Organism may grow inward & through shaft to
form nodular swellings spaced irregularly along
the axis.
 Hair weakened at these point hence easily
breaks.
 Growth occurs as collarette around hair shaft &
consist of mycelia that rapidly fragment into
arthrospores.

10.  Clinical features-
 Soft, white, grayish or light brown nodules on
hair shaft.
 Seen mainly on distal portion of facial &
axillary hair, beard, moustache, pubic hair
 Pruritis, pain, inflammation.
 Hair can be easily breaks. Mass can be easily
detached from shaft.
 Infection may accompanied by bacteria like
corynebacterium.

11. Nodules of white piedra

12.  Differential diagnosis-
- Trichomycosis axillaris
- Phthiriasis pubis
- Pediculosis capitis.
- Geotrichum spp. infection.

13.  Lab diagnosis-
 Do not fluoresce on Wood’s Lamp examination.
 On microscopy- fungus is seen like concretion that
are composed of hyphae & rectangular arthrospores
within & around hair. (KOH & LPCB)
 Culture is done on SDA with chloramphenicol. Moist
yeast like cream colored colonies.
 Assimilation of glucose, maltose, sucrose, galactose
& lactose.
 Breaks down urea.

15. Black Piedra
Is also nodular type of infection caused by Piedra
hortae.
Also called as ‘tinea nodosa’.
Mycology-
- Exists in a perfect state during colonisation.
- Family- Piedraiaceae
- Order- Dothideales
- Class- Pyrenomycetes.
- Phylum- Ascomycota.

16.  Epidemology-
 Found in tropical countries in warm & humid
climates.
 Central & South America, Southeast Asia in
population where hair care is done with oily
substances.
 Exists in soil. Affects humans & animals.

17.  Pathogenesis and pathology-
 Infection starts under cuticle of hair shaft with
stone hard, black nodule.
 Fungal mass enlarge & grow outside the hair &
completely envelop the shaft.
 Mature nodule in periphery composed of aligned
hyphal strands
 Fungus destroys cuticular layers, cortex leads to
destruction of hair shaft & breakage of hair.

19.  Clinical features-
 Formation of discrete, gritty, hard, brown black
nodules firmly attached to hair shaft.
 Affect mainly hair of scalp.
 Moustache, beard & pubic hair may be
affected.
 Itching usually absent.

20.  Lab Diagnosis-
 Crushed brittle nodules on KOH mount.
 Dark colored thick walled septate hyphae.
 Culture on SDA with chloramphenicol,
glycerine & cycloheximide.
 Slow growing, adherent, coal black,
cerebriform colonies.
 LCB mount shows dark walled septate hyphae
with chlymydospores.
 Microculture technique using DTM

22.  Treatment & prophylaxis-
 Ideal T/t for both piedra is shaving off hair in
affected part.
 May not feasible in women.
 Oral azols × 3-4 weeks with topical antifungals ×
3-4 months
 Topical azols, ciclopirox olamine, chlorhexidine
solution, amphotericin B lotion etc.
 Terbinafine 250mg/day × 6 wks for Black piedra.
 Good personal hygiene.

23. Dermatophytes causing Hair infection
 Are most common types of cutaneous fungal
infections in humans affecting skin, hair & nail.
 Also known by terms like ‘tinea’ OR ‘ringworm’.
Trichophyton Skin, Hair & Nails
Microsporum Skin & Hair
Epidermophyton Skin & Nails

24.  Hair infections caused by dermatophytes-
 Tinea capitis
 Favus
 Kerion
 Tinea barbae

25.  Tinea capitis-
 Infection of shaft of scalp hair & present as
 Inflammatory
 Noninflammatory
 Infected hairs appears dull & grey.
 Base of hair shaft & follicle are involved.
 Breakage of hair at follicular orifice which
creates patches of alopecia with ring
formation.
 Clinical types

26. Kerion-
- Caused by T. verrucosum & T. mentagrophytes
- Severely painful inflammatory reaction producing
raised, boggy mass on scalp
- Follicles discharging pus, sinus formation at
multiple points
- Thick crusting with matting of adjuscent hairs.
- ‘Kerion celsi’

27.  Favus (Tinea Favosa)
 Caused by T. schoenleinii
 Form cup like crusts around infected follicles.
 Fungal growth within hair is
minimal which remains intact.
 Patchy alopecia, scarring.
 Black-dot
 Caused by T. tonsurans & T. violaceum
 Endothrix like invasion.
 Breakage of hair near surface results in blackdot
appearance.

28. Ectothrix infections
• The arthrospores
appear as mosaic
sheath around hair
or on surface of hair
shaft.
• Cuticle remains
intact.
Endothrix infection
• Hyphae form
arthrospores within the
hair shaft
• Cuticle usually get
destroyed.
Ectothrix Endothrix
T.mentagrophytes T.schoenleinii
M.canis T.tonsurans
M.gypseum T.violaceum
M.audouinii T.Soudanense
T.verrucosum
T.Rubrum

30.  Tinea barbae
 Caused by T.verrucosum, T.mentagrophyte,
M.canis
 Ringworm infection of beard & moustache
areas
 Also called as ‘Barber’s itch’.
 Erythematous patches on face, scaling
 Fragile & lusterless hair.

31. Diagnosis-
Clinical examination
History- age, occupation, hobbies, living
conditions, onset, duration & progress.
Lab diagnosis-
Microscopy
Isolation of fungus in culture
Serological tests

32. Direct examination-
KOH wet mount simple & reliable
Basal root portion of hair is taken by plucking & not by
clipping
Fungus is seen as branching hyaline mycelia with
arthrospore production

33. Wood lamp examination-
Principle
Flurescence produced mainly by microsporum & rarely
by trichophyton spp.
Microorganisms Fluorescence color
M.Audouinii Bright green
M.Canis Bright green
M.ferrogineum Blue green
M.gypseum Dull yellow
T.schoenleinii Dull yellow
Malessezia furfur Golden yellow
Coeynebacterium Coral red

34. Fungal culture-
SDA with cycloheximide incubated at 3 temp. i.e.
25˚C, 30 ˚C & 37 ˚C.
Colony morphology & LCB microscopy
 DTM – dermatophytes turns medium into red color.
DIM- to avoide false positive results given by DTM
Species Colony morphology LCB mount
Trichophyton
spp.
Powdery, velvety, waxy with pigment Macroconidia- sparse,
pensil shaped with blunt
end
Microconidia-abundunt
Microsporum Cottony, velvety, powdery with white
to brown pigment
Macroconidia- abundunt,
spindle shaped, rough.
Microconidia- scanty

35. Immunodiagnosis
Skin test with dermatophytic Ag ‘trichphytin’.
Serological tests- immunodiffusion
PCR fingerprinting
Animal pathogenicity-
To study the nature of the lesion & immunity
produced by organisms.

36.  Treatment & prophylaxis-
 Topical antifungals
 Oral griseofulvin 10mg/kg (for nail & scalp)
 Or single dose 2gm in adults.
 Micronised prepatrations.
 Resistance
 Itraconazole, fluconazole & terbinafine therapy for 12
weeks
 ‘Live spore vaccine’, killed cell vaccine & soluble
cytoplasmic extract for T. mentagrophyte.
 Good personal hygiene.

37. Thank you…