Alopecia areata is an autoimmune disease that leads to patchy hair loss. It commonly affects the scalp but can occur anywhere on the body. Characterized by the immune system mistakenly attacking hair follicles, alopecia areata manifests in various forms. One notable diagnostic feature associated with this condition is the presence of exclamation point hairs.
"Alopecia" is a medical term for hair loss or baldness, and "areata" indicates that it occurs in small, random areas. Alopecia areata is a common condition, affecting nearly 7 million people in the United States. Approximately 20% of cases involve children. It is the second-most common form of hair loss, following male and female pattern baldness.
There are several classifications of alopecia areata, depending on the extent and location of hair loss:
Anyone can develop alopecia areata, but the chances are higher if:
Alopecia areata causes hair to fall out in patches, typically small and round, about the size of a quarter. However, the shape and size of the patches can vary. Nails may also develop dents or pits (cupuliform depressions), feeling coarse or gritty.
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Alopecia areata primarily affects psychosocial well-being (how society and social groups affect your thoughts and emotions) and psychological health (how you think about yourself and your behavior).
Exclamation point hairs, also known as exclamation mark hairs, are a vital sign that dermatologists look for when diagnosing alopecia areata. These hairs are short and fragile, thinner at the base where they attach to the body than at the other end.
These irregularly shaped hairs are noticeably shorter than regular hairs on the scalp, typically growing only 3-4 mm in length. Inflammation weakens the hair shaft, causing it to break, resulting in a shape resembling an exclamation point. Normal hairs are thick near the base and thin outwards, while exclamation point hairs are thin where they attach to the skin and thicker on the other end.
The presence of exclamation point hairs helps doctors determine the type of hair loss. In alopecia areata, these disordered hairs may be present around the edges of a patch of hair loss. They may also be present on various parts of the body in someone with alopecia totalis. However, they are typically absent in alopecia universalis, where all body hair is lost.
Exclamation point hairs differ from normal hairs because they do not grow past the 3-4 mm mark. The body’s inflammatory response makes them fragile, leading them to fall out. Additionally, their unique shape-thin at the base and thicker at the end-contrasts with the structure of regular hairs.
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Microscopic studies reveal structural differences in the distal end of exclamation point hairs compared to normal hair shafts. Transverse sections often show asymmetrical cortex disintegration, with one side compact and homogeneous and the other deeply fissured. Many tips lack a cuticle and have irregular profiles. Melanin may be found in cortical and medullary fragments at the tip.
Tapered hairs are frequently seen in patients with small circular patches of alopecia areata. In contrast to 4-5 mm exclamation mark hairs, tapered hairs are long and typically as long as neighboring hairs. As the hair enters into the skin it becomes much thinner. At the bottom of the exclamation mark hair (deep under the skin) is inflammation.
Diagnosing alopecia areata involves a medical history, physical examination, and sometimes additional tests.
A doctor will ask questions about your hair loss, examine the pattern of hair loss, and check your scalp. A dermatoscope, a magnification tool with special lighting, may be used to examine the skin, hair, and nails.
A sample of your hair may be taken and examined under a dermatoscope. This helps in identifying characteristic features like exclamation point hairs.
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Blood tests may be conducted to check for underlying conditions, such as thyroid problems, that could be contributing to hair loss.
The presence of stippling or pitting (rows of tiny dents) on the fingernails can also indicate alopecia areata. Trachyonychia, characterized by rough ridges going lengthwise down the nails, may also be observed.
Alopecia areata is widely considered an autoimmune disorder where the body mistakenly attacks hair follicles. What triggers this response is not fully understood, but many cases are associated with stress, shock, bereavement, illness, or accidents.
There is often a genetic predisposition for alopecia areata, with many reported cases occurring in twins.
Alopecia areata is more common in people who suffer from other autoimmune conditions such as eczema, Addison’s disease, pernicious anemia, rheumatoid arthritis, ulcerative colitis, lichen planus, diabetes mellitus, vitiligo, lupus, and thyroid disease.
While there is currently no cure for alopecia areata, several treatments can help manage the condition and encourage hair regrowth.
In up to 50% of cases, alopecia areata resolves spontaneously within a year.
Hair transplants are generally not recommended for people with alopecia areata because the condition can recur and affect transplanted hairs.
Alopecia areata is an unpredictable condition. While up to 50% of people affected find that their hair grows back spontaneously within a year, some do not see improvement. Recurrences are common. Rarely, it may progress to alopecia totalis or universalis, in which cases full regrowth is uncommon.
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