Black piedra: the first case treated with terbinafine (Lamisil)

A 23-year-old Swedish Caucasian man presented with typical clinical signs of black piedra of his scalp after his return from 4-months' stay in India. There were black nodules around the hair shafts, and the crushed nodules revealed numerous asci and ascospores on microscopy. Piedraia hortae was isolated from the concretions. He was treated with oral terbinafine 250 mg daily for 6 weeks. At the end of treatment no nodules were visible, but 16 days later a few 'new' black concretions appeared. Microscopy of these nodules revealed markedly degenerated fungal elements, and cultures were negative. No further signs of the disease were seen 2 months after cessation of therapy. In vitro susceptibility tests showed that Piedraia hortae was sensitive to terbinafine. This case demonstrates that terbinafine is effective in the treatment of black piedra.