White Piedra

A 4-year-old girl presented to the dermatology clinic with a 2-month history of progressively worsening white spots on her hair that were unresponsive to 3 applications of permethrin 1% lotion for presumed pediculosis capitis. No family members had similar lesions. She was born in Cleveland, Ohio, and the parents denied any travel to tropical or subtropical climates. The patient had long hair which she kept tied back in a damp ponytail after shampooing. On physical exam, many irregularly distributed, white nodules were loosely adherent to distal hair shafts (Figure 1).