What is the best course of treatment for a 14-year-old female patient with recurrent furuncles (boils), oligomenorrhea (irregular periods), and hirsutism (excessive hair growth), with a family history of a maternal condition, and laboratory tests ordered including full blood count (FBC), glucose, liver function tests (LFT), renal function, C-reactive protein (CRP), thyroid function, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and a polycystic ovary syndrome (PCOS) screen?

Treatment of Recurrent Hidradenitis Suppurativa with Suspected PCOS in an Adolescent

This 14-year-old requires dual-track management: immediate treatment of active hidradenitis suppurativa (HS) with systemic antibiotics and lifestyle modifications, while simultaneously pursuing PCOS diagnosis through the ordered laboratory tests, followed by hormonal therapy with combined oral contraceptives once PCOS is confirmed. 1, 2

Immediate Management of Hidradenitis Suppurativa

Acute Treatment

• Complete a full course of systemic antibiotics (typically tetracycline-class antibiotics like doxycycline or minocycline for 10-12 weeks) for the current active lesions, as incomplete antibiotic courses lead to treatment failure and recurrence 1
• Ensure strict adherence to the full antibiotic regimen, as this patient's previous incomplete course directly contributed to symptom recurrence 1
• Consider incision and drainage only if fluctuant abscesses are present, though this should be avoided when possible as it may worsen scarring 1

Long-term HS Management

• Smoking cessation counseling is mandatory, as 70-75% of HS patients smoke and smoking is associated with disease severity and treatment failure 1
• Weight management is critical, as obesity prevalence exceeds 75% in HS patients and substantial weight loss (>15% body weight reduction) leads to complete remission in 48.6% of patients 1
• Resume bleach baths (0.005% sodium hypochlorite solution) 2-3 times weekly despite shower-only accommodation—this can be accomplished by diluting bleach in a basin for affected area soaking 1
• Screen for diabetes with the ordered glucose testing, as HS patients have a 1.5- to 3-fold increased risk of type 2 diabetes with prevalence up to 30% 1

PCOS Diagnostic Confirmation

Laboratory Interpretation Strategy

• Await results of the comprehensive metabolic and hormonal panel already ordered (FBC, glucose, LFT, renal function, CRP, thyroid function, FSH, LH, PCOS screen) before initiating hormonal therapy 2
• Total testosterone or free testosterone using LC-MS/MS is the primary diagnostic test, with pooled sensitivity of 74% and specificity of 86% for PCOS diagnosis 2
• TSH and prolactin levels are mandatory to exclude thyroid disease and hyperprolactinemia, which can mimic PCOS symptoms 1, 3
• Two-hour oral glucose tolerance test with 75g glucose load is required to screen for glucose intolerance and type 2 diabetes, as all women with PCOS should be screened due to demonstrated increased risk 1, 2
• Fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) is essential, as PCOS patients frequently have dyslipidemia with disproportionately elevated LDL cholesterol 1, 2

Critical Diagnostic Considerations

• PCOS can be diagnosed with only clinical hyperandrogenism (hirsutism) plus irregular menstrual cycles, even if all laboratory values return normal—the Rotterdam criteria require only 2 of 3 features (oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovarian morphology) 2
• Do not order pelvic ultrasound in this 14-year-old, as ultrasound should not be used for PCOS diagnosis in those with gynecological age <8 years after menarche due to high incidence of multifollicular ovaries being a normal finding 2
• Total testosterone is abnormal in only 70% of women with confirmed PCOS, meaning normal testosterone does not exclude the diagnosis when clinical features are present 2
• LH/FSH ratio >2 is abnormal in only 35-44% of PCOS patients, making it a poor standalone diagnostic marker 2

Hormonal Treatment Once PCOS is Confirmed

First-Line Therapy

• Initiate combined oral contraceptives (OCPs) as first-line therapy for both PCOS and hirsutism management, as OCPs effectively suppress ovarian androgen production and increase sex hormone-binding globulin 4, 5, 6
• OCPs address multiple issues simultaneously: menstrual irregularity, hirsutism, and provide contraception (essential when adding antiandrogens) 4, 6
• Metformin 850mg daily can be added in lean adolescents or escalated to 1.5-2.5g daily in overweight/obese adolescents as first-line monotherapy or in combination with OCPs 4

Antiandrogen Therapy for Moderate-Severe Hirsutism

• Add spironolactone (50-200mg daily) to OCPs for moderate to severe hirsutism (this patient requires shaving every few days, indicating significant severity) 4, 5, 6
• Alternative antiandrogens include cyproterone acetate or finasteride (5α-reductase inhibitor), though spironolactone is most commonly used 4, 5
• Antiandrogens must be combined with reliable contraception due to teratogenic risk, making OCPs the ideal combination 4, 5

Adjunctive Cosmetic Treatments

• Topical eflornithine hydrochloride 13.9% cream can be applied to facial areas to slow hair growth 5
• Continue mechanical hair removal (shaving is safe and does not worsen hirsutism) during medical treatment 7, 5
• Consider laser hair removal or electrolysis for long-term hair reduction once hormonal therapy is optimized 7, 5

Timeline Expectations and Monitoring

Response Timeline

• Hirsutism improvement requires 6-8 months minimum before observable response, with some patients requiring 12-18 months 7, 6
• HS improvement should be seen within 10-12 weeks with appropriate antibiotic therapy and lifestyle modifications 1
• Menstrual regularity typically improves within 3 months of OCP initiation 4

Ongoing Surveillance

• Screen for PCOS-related comorbidities including depression/anxiety (44% prevalence in HS patients), metabolic syndrome, and cardiovascular risk factors 1
• Monitor for post-inflammatory hyperpigmentation from HS lesions and consider topical treatments once active inflammation resolves 1
• Assess for squamous cell carcinoma in chronic HS lesions, particularly on perineum and buttocks, through periodic skin examination 1
• Cardiovascular risk factor monitoring every 6-12 months including weight changes and blood pressure 2

Critical Pitfalls to Avoid

• Never diagnose PCOS without excluding thyroid disease and hyperprolactinemia first, as these conditions can mimic PCOS and require different treatment approaches 3
• Do not use ultrasound for PCOS diagnosis in this adolescent, as it has poor specificity and high false-positive rates in young women 2
• Do not prescribe antiandrogens without reliable contraception due to teratogenic risk 4, 5
• Do not expect rapid improvement in hirsutism—counsel the patient that medical therapy requires 6-12 months minimum, and premature discontinuation leads to treatment failure 7, 6
• Do not allow incomplete antibiotic courses for HS, as this patient's previous incomplete treatment directly caused recurrence 1
• Screen for the maternal condition (likely PCOS given family history pattern) and counsel about hereditary nature of both PCOS and HS 1, 5