Ultrastructural study of exclamation-mark hair shafts in alopecia areata

The prime diagnostic feature of acute alopecia areata is the presence of exclamation mark hairs. These characteristic hairs fracture at their distal end and taper proximally towards the scalp, giving them the appearance of an exclamation mark. Hair morphology was studied in 8 patients with untreated acute alopecia areata and 3 normal adults without hair loss. Light microscopy, transmission and scanning electron microscopy revealed distinct structural differences in the distal end of hairs compared with the remainder of their length and with normal hair shafts. Transverse sections of hairs just below the frayed brush-like tip often displayed asymmetrical cortex disintegration. One side was compact and homogeneous while the other was deeply fissured and/or broken up into discrete heterogeneous-staining fragments of cortical, stratum corneum and cuticular components in addition to apparently degenerate cortex. Many exclamation mark hair tips lacked cuticle and had irregular profiles. Melanin was found in cortical and medullary fragments at the tip, although it was absent in the more degenerate forms of cortex. More proximal sections of these pathognomic telogen hairs revealed nearly normal hair shaft ultrastructure.