Hair-on-end appearance is a radiographic feature associated with which condition?

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Hair-on-end appearance on skull radiographs signals marrow expansion from chronic hemolytic anemia, most classically seen in beta-thalassemia major. When the body tries to produce more red cells over a long period, the marrow spaces in the cranial bones expand (marrow hyperplasia). This growth causes the inner and outer tables of the skull to thin and the vertical trabeculae to become pronounced, producing fine, hair-like radiating lines that give the skull a hair-on-end look. It’s a hallmark of significant erythropoietic activity and extramedullary hematopoiesis in severe anemia. This pattern is not typical for conditions like congenital syphilis or hemophilia, which have different skull radiographic findings.