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Stem
A 14-year-old girl is brought with a 9-month history of an irregular patch of hair loss over the crown. Examination shows incomplete alopecia with residual hairs of many different lengths, no scale, and preserved follicular openings. She reluctantly admits to pulling hair when stressed and sometimes chewing it. Trichoscopy shows flame hairs, V-sign and hair powder. She has no fever or abdominal pain.
Questions
a) What is the most likely diagnosis, and which clinical and trichoscopic features support it over alopecia areata? (3 marks)
b) Outline first-line management, including the behavioural approach of choice. (3 marks)
c) Summarise the key adult versus paediatric evidence for N-acetylcysteine. (2 marks)
d) What emergency complication of trichophagia must parents be warned about, and what symptoms prompt urgent review? (2 marks)