Clinics in Dermatology (2010) 28, 140–145

Tinea versicolor, tinea nigra, white piedra, and black piedraAlexandro Bonifaz, MB, MSc a,⁎, Fernando Gómez-Daza, BL, MSc b,Vanessa Paredes, MDa, Rosa María Ponce, MDa

aDermatology Service and Mycology Department, General Hospital of Mexico DO, Dr. Balmis 148,Colonia Doctores México DF, 06720, MexicobDermatology Postgraduate Section, University of Carabobo, Valencia, Venezuela

Abstract Superficial mycoses are fungal infections limited to the stratum corneum and its adnexalstructures. The most frequent types are dermatophytoses or tineas. Tinea versicolor involves the skin inthe form of hypochromic or hyperchromic plaques, and tinea nigra affects the skin of the palms withdark plaques. White piedra and black piedra are parasitic infections of scalp hairs in the form ofconcretions caused by fungal growth. Diagnosis of these mycoses is made from mycologic studies,direct examination, stains, and isolation, and identification of the fungi. Treatment includes systemicantifungals, topical antifungals, and keratolytics.© 2010 Elsevier Inc. All rights reserved.

Introduction

Superficial mycoses are fungal infections of the skin andits adnexal structures (hairs and nails) that invade solely thestratum corneum and the most superficial layers of the skin,causing minimal to no inflammatory reaction. The mostfrequent are tineas or dermatophytoses, tinea versicolor andtinea nigra and piedras (white and black). This chapter willrefer to the latter four mycoses.1,2

Tinea versicolor

Tinea versicolor (pityriasis versicolor) is a superficialmycosis caused by various yeasts and lipophilic fungi of thegenus Malassezia, with three dominant species: M globosa,M sympodialis, andM furfur. Tinea versicolor is characterizedby the presence of fine scaly patches (pityriasis) or macules,

⁎ Corresponding author.E-mail address: a_bonifaz@yahoo.com.mx (A. Bonifaz).

0738-081X/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.clindermatol.2009.12.004

which may be hypochromic or hyperchromic (versicolor), thatare generally located on the upper aspects of the trunk, neck,and arms.3,4 It may extend to the face, groin, and even thethighs, whereas in children, the face is frequently involved.

Tinea versicolor has been reported worldwide but ispredominant in tropical climates. It has been found innewborns and elderly patients, although it is morefrequent in young adults and is equally distributedbetween men and women. The most important predispos-ing factors are heat, humidity, use of oily tanning lotionsand creams, and corticosteroids.3,5

The two clinical varieties are hypochromic or hypopig-mented, which generally occurs in dark-skinned individualsand is characterized by hypochromic patches or maculescovered with fine scales that are initially irregular with smallborders that converge to form large patches (Figures 1 and 2).The hyperchromic or hyperpigmented variety consists oflight brown patches with scales on the surface. Mixed casesmay be found, especially in the axillary region, the groin, andthe submammary folds. Both clinical varieties are asymp-tomatic, and only a few patients complain of itching.

Fig. 1 Hypochromic tinea versicolor.

Fig. 2 Hypochromic tinea versicolor (close-up).

Fig. 3 Retroauricular seborrheic dermatitis.

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Although the hypochromic variety is observed in dark skinand the hyperchromic variety in fair skin, inverse cases maybe found. It is important to distinguish both varieties from

Fig. 4 Folliculitis due to Malassezia is shown in panoramic andclose-up views.

Fig. 5 Direct examination shows cluster yeast cells and shorthyphae (potassium hydroxide and blue Parker stain; originalmagnification, × 20).

142 A. Bonifaz et al.

pityriasis alba, hypochromic solar dermatitis, pityriasis rosea,and postlesional melanodermas.3,6 Rarely, tinea versicolormay occur in chronic cases as a papuloid variety; recently,atrophic and imbricata varieties have been reported.2,3,6

Among the infections caused by Malassezia spp (malas-sezioses) are a group of diseases related to these lipophilicyeasts. These microorganisms can be bystanders or theetiologic agent.2,7,8

Table 1 Main characteristics of tinea versicolor, tinea nigra, white p

Superficialmycoses

Etiologicagent

Clinical location

Tinea versicolor M. globosa Upper part of thetrunk, neck, arms

(Pityriasis versicolor) M. sympodialis Face (children)

M. furfurMalassezioses

Seborrheicdermatitis

M. globosa Scalp, central areasof face, eyebrows

Folliculitis M. sympodialis Trunk, shouldersOnychomycosis M. furfur Nails (hand)

M. restrictaTinea nigra Hortae

werneckiiPalms and soles

White piedra T. cutaneum Scalp hairsT. ovoides Facial, axillary,

and pubic hairT. inkin Perianal hair (HIV patients)

Black piedra Piedraia hortae Scalp hairs

Seborrheic dermatitis is a benign, chronic, erythematos-quamous dermatosis that has multiple causes. The mostimportant factors are hormonal, environmental, psychologic,immunologic, and infectious (Malassezia spp). The mostcommon manifestation is scalp scaling (“dandruff”). It canalso affect the nasolabial folds, eyebrows, glabella, theretroauricular area, and the central region of the chest.Seborrheic dermatitis is generally asymptomatic, but somepatients have mild pruritus (Figure 3). Malassezia spp arefound in most cases, especially M globosa, M furfur, and Mrestricta. Seborrheic dermatitis is more frequent in patientswith HIV infection. The use of topical and systemicantifungals decreases the signs and symptoms.2,4,7,8

Folliculitis due to Malassezia (FM) is a superficialinfection of the pilosebaceous unit. M globosa, M furfur,andM pachydermatis are the species that have been isolated.FM usually affects the trunk, the shoulders, and exception-ally, the face. Clinically, it presents as pustules localizedaround the follicles without comedones, which distinguishesit from acne (Figure 4). Histologically, there is folliculardilatation and inflammatory infiltrate with yeast coloniza-tion. FM is more frequent in young adults and is consideredan opportunistic infection.2,7

Onychomycosis due to the Malassezia spp is a rareinfection that has caused controversy. Some cases associ-ated with M globosa and M furfur have been reported.Clinically, it is a distal subunguial onychomycosis that issimilar to dermatophytic infection. Some authors consider it

iedra, and black piedra

Clinical presentation Treatment

Hypo-and hyperpigmented,macules with light scales

Topical antifungals: imidazoles,terbinafine, ciclopiroxolamineOral antifungals: ketoconazole,itraconazole, fluconazole

AsymptomaticTopical antifungals: imidazoles,ciclopiroxolamine

Erythematosquamous Oral antifungals: ketoconazole,itraconazole

Folliculitis, pustulesDistal subungual

Brown to gray patches Control of hyperhidrosis

Asymptomatic Topical antifungals andkeratolytics

White stone-like concretions Shaving or clipping infected hairsTopical antifungals

Asymptomatic KeratolyticsBlack stone-like concretions Shaving or clipping infected hairs

Topical antifungalsAsymptomatic Keratolytics

ig. 6 Tinea nigra presents as brown-black macules on the palm.

143Superficial mycoses

a true infection, but others believe that the yeasts found areonly carriers.2,4,7

Colonization by Malassezia has also been reported to beassociated with diverse diseases such as atopic dermatitis,psoriasis, blepharoconjunctivitis, dacryocystitis, confluentand reticulated papillomatosis (Gougerot-Carteaud), system-ic infections, and endocarditis.2,7

Laboratory diagnosis is made by skin scraping. Directexamination is done with 10% potassium hydroxide (KOH)solution, adding Parker blue ink (Quink Co.). Clusters ofsmall blastoconidia or round budding yeast cells and shortseptate and, occasionally, branching filaments are observed(Figure 5). Cultures are not necessary for the diagnosis if amicroscopic image is available. Cultures are performed onSabouraud agar media plus antibiotics, adding 5% to 15%olive oil and Dixon's agar. They are incubated at 25° or37°C for 8 days and yield creamy, whitish-yellow colonies(Malassezia spp). Under the microscope, round or “globus”blastoconidia are generally observed, although they can beelongated, depending on the species. Woods light (ultravi-olet) is very useful. Tinea versicolor patches or maculesemit a characteristic yellow-green fluorescence. A biopsyspecimen is not necessary. An inflammatory process may beobserved. Filaments and yeast cells are found on thesuperficial layers of the skin and are easily visible withperiodic acid-Schiff stain.2,4

Treatment consists of topical and systemic therapy. Thefirst is recommended for limited or initial cases. Treatmentmust be administered for 2 to 4 weeks, as a minimum. Alsouseful are sodium hypochlorite (20%), propileneglycol(50%), and imidazoles, such as miconazole, clotrimazole,ketoconazole, bifonazole, as well as allylamines (terbinafineand naftifine) and ciclopiroxolamine. These antifungal drugsmay be preferred in noncreamy forms, such as a gel and aspray, when available.3, 6

Systemic therapy is suggested in very extensive orrecurrent cases. The three most recommended antifungalsare ketoconazole, 200 mg/d for 7 to 15 days; itracona-zole, 200 mg/d for 5 to 10 days; and fluconazole, 400 mgfor 1 day.2,6,7

To avoid constant relapse, it is necessary to suppresspredisposing factors as much as possible, especiallyexcessive sun exposure, use of oily tanning lotions, andexcessive sweating, which can be avoided by usingdesiccants (talcum powder; Table 1.

ig. 7 Direct examination shows multiple dark, septate, hyphae,nd yeast cells (10% potassium hydroxide stain; original magni-cation × 10).

Tinea nigra

Tinea nigra is a superficial mycosis caused by a pigmentedyeast, Hortaea werneckii (previously Phaeoannellomyces orExophiala werneckii). It is a dematiaceous, polymorphic,halotolerant, and halophilic fungus; that is, it grows in anaqueous medium and adapts easily to hypersalinity.9,10

Most cases occur in tropical regions, especially coastalzones, and have been observed in young men and women

F

and frequently in children. The most important predis-posing factor is hyperhidrosis of the hands and the feet.This is considered to be essential for development offungal infection.9,11

The main clinical locations are the palms and sometimesthe dorsal aspect of the hands, generally unilateral, and to alesser degree, the soles, arms, legs, neck, and trunk. Tineanigra is a chronic condition that presents as hyperpigmented,irregular, circumscribed patches or spots ranging in colorfrom tan to dark brown or black, covered with fine scales,and usually asymptomatic (Figure 6).9-11

Laboratory diagnosis is performed by direct examinationof the skin scales with 10% to 20% KOH solution. Dark,septate hyphae are observed with occasional clusters of yeastcells (blastoconidia; Figure 7). The usual cultures onSabouraud agar media (28°C) initially yield creamy coloniesof yeast cells, which later become filamentous with hyphaeand acropetal conidia. Biopsy specimens are not necessary

Fafi

Fig. 8 Dermoscopy of tinea nigra reveals a hyperpigmentedfungal growth. (Photograph courtesy of Leonel Fierro, MD).

Fig. 10 Mycotic nodules (spores) of white piedra (10%potassium hydroxide stain; original magnification, × 10).

144 A. Bonifaz et al.

for diagnosis. With hematoxylin and eosin stain, numerouspigmented spores and hyphae are observed at the level of thestratum corneum.7 Dermoscopy reveals a hyperchromicfungal growth stain. This technique is useful to differentiatetinea nigra from nevi, especially melanoma (Figure 8).12,13

Treatment is simple, because control of hyperhidrosissuffices. Keratolytics, such as 3% salicylic acid, Whitfieldointment, and topical antifungals such as bifonazole,clotrimazole, ketoconazole, terbinafine, and ciclopiroxola-mine may be used. Oral itraconazole (100 mg/d) is effective(Table 1).9-11

White piedra

Piedra is the Spanish word for stone, and it was theoriginal name of both white and black piedra. This is asuperficial mycosis caused by yeast-like organisms of thegenus Trichosporon, mainly T cutaneum, .n ovoide, and

Fig. 9 White piedra of scalp hairs.

T inkin. It is a chronic, asymptomatic infection thataffects the hair shaft, preferably scalp hair shafts, and toa lesser extent, those of the beard, moustache, axillasand pubis, in the form of concretions or soft, whitishnodules.1,2,14 Most cases occur in tropical regions andare observed in young men and women and in children.The most important predisposing factors are humidity,hyperhidrosis, and poor personal hygiene.2

The most affected hairs are those of the scalp, but it mayalso be found in the axillae, pubis, and exceptionally, thebeard, eyebrows, and eyelashes. White piedra is anasymptomatic condition. The hair is infected with small,soft concretions that are not initially visible and can only bepalpated. A 1-to 3-mm whitish concretion with well-definedborders (Figure 9) subsequently develops, and a single shaftmay have one to several concretions. It is important todifferentiate the concretions from pediculosis (nits), trichor-rhexis nodosa, monilethrix, and hair caps.2,15 Perianal hairsmay have similar presentations in HIV-positive patients.16

Fig. 11 Mycotic nodules (spores) of black piedra. (10%potassium hydroxide stain; original magnification × 40).

145Superficial mycoses

Laboratory diagnosis is performed with infected hairstreated with 10% to 20% KOH and examined under themicroscope. They are made up of concretions formed bymasses of septate hyphae with numerous septa and densezones of arthroconidia (Figure 10). In cultures on Sabouraudagar media, etiologic agents yielded limited, similar, wet,yeast-forming colonies with a brain-shaped appearance.Identification is based on biochemical tests and micromor-phologic aspects. Trichosporon species form true hyphae,arthroconidia, and blastoconidia.2,17

Treatment involves clipping the infected hairs; if thedisease is widely disseminated, shaving the whole area issuggested. Subsequently, topical antifungals may be used,such as 1% mercury bichloride, 1% iodinated solution, or30% salicylic acid solution. Good results have been reportedwith topical imidazoles such as econazole, isoconazole, ormiconazole. The use of 2% ketoconazole shampoo isextremely effective and practical (Table 1).2,15

Black piedra

This is a superficial mycosis caused by Piedraia hortae, apigmented fungus. It is a chronic, asymptomatic infectionthat generally affects the hair shafts of the scalp in the form ofblack, hard concretions or mycotic nodules.1,2 Most casesoccur in tropical regions with high rainfall in young men andwomen and in children. The most important predisposingfactors are humidity and poor personal hygiene.2,18

The disease is asymptomatic and is most frequentlylocated on the hairs of the scalp, beard, and sporadically, theaxillae and pubis. The morphology is very similar to that ofwhite piedra. Brown or black, limited, spindle-shape hardconcretions are formed with the appearance of “grits” orsmall stones, hence its name.18,19

Laboratory diagnosis is performed with infected hairstreated with 10% to 20% KOH and examined under themicroscope. Pigmented brown ochre nodules are observed.Concretions are masses formed by pseudoparenchymaltissue that is made up of septate, thick-walled hyphaesimulating arthroconidia. It is possible to see asci with two ormore ascospores (this image is characteristic; Figure 11). Inculture, the fungus grows at room temperature in Sabouraudagar media, presenting black-greenish, limited, acuminate

colonies and is identified by its micromorphology. Thefungus presents a teleomorphic phase composed of fusiformasci and ascospores.1,18

Treatment for black piedra is the same as for white piedra:clipping infected hairs and applying a topical antifungal orkeratolytic (Table 1).2

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