Reference: Jan-Feb 2025 | Issue 1 | Vol 18 | Page 33
Exploring the management of acne, rosecea, and eczema in primary care
Skin conditions are among the most frequent reasons for consultations in general practice.1 Acne, rosacea, and eczema, in particular, are three prevalent dermatological disorders that can significantly impact patients’ quality-of-life. Understanding their pathophysiology, clinical presentation, and evidence-based management is important for effective treatment.
ACNE VULGARIS

Acne is a multi-factorial skin disorder influenced by a combination of genetic, hormonal, microbial, and environmental factors.2 Genetics play a role, and studies show that individuals with a family history of acne are at greater risk. Genetic factors impact key processes involved in acne development, such as sebum production, follicular keratinisation, and the immune system’s response to Cutibacterium (C.) acnes.
Environmental influences, including diet, climate, pollution, and lifestyle, also contribute to acne severity. Diets rich in high glycaemic-index foods and dairy products are linked to worsened acne, likely due to their effects on insulin-like growth factor 1 (IGF-1) signalling, which can elevate sebum production and inflammation.3,4
Acne is also influenced by hormonal factors, particularly those that alter sebaceous gland function. Androgens play a significant role by stimulating sebocyte proliferation, increasing lipid accumulation within the cells, and causing hyperkeratinisation of the follicular infrainfundibulum, which leads to excessive sebum production and worsens acne severity.
Beyond localised hormonal effects, systemic hormonal imbalances, such as those seen in adult acne, are also significant triggers. Stress further exacerbates acne by causing hormonal fluctuations that heighten sebum production.2,3,4
The skin microbiome, comprising C. acnes, coagulase-negative Staphylococcus, and various fungal species, is important for maintaining skin homeostasis. Although C. acnes proliferation is associated with acne, it is the specific phylotypes and diversity of C. acnes that are more directly linked to acne pathogenesis.2,3,4
Clinical presentation
Acne typically affects areas with a high density of sebaceous glands. The face is the most common site, with lesions frequently appearing on the forehead, nose, cheeks, and chin. Acne on the chest and back can be more challenging to treat due to the thicker skin and larger sebaceous glands.
Less commonly, the shoulders and upper arms are affected, but can still present with significant lesions. The lesions can be categorised as non-inflammatory, which include open comedones (blackheads) and closed comedones (whiteheads), or inflammatory, which manifest as papules, pustules, nodules, and cysts.2,5
The prevalence of acne decreases with age; however, it can still pose a significant dermatological issue for adults. While acne is common in males during adolescence, it predominantly affects females in adulthood.2,5
Diagnosis
Diagnosis of acne is primarily clinical, based on the characteristic appearance and distribution of lesions. Severity is classified as mild, moderate, or severe to guide treatment. The goal is to accurately identify the type and severity of acne, differentiate it from other dermatological conditions, and determine any underlying factors that may contribute to its occurrence.6,7
Differential diagnosis is important to distinguish acne from similar skin conditions, including rosacea, folliculitis, perioral dermatitis, seborrhoeic dermatitis, keratosis pilaris, and hidradenitis suppurativa.2,6,7
A thorough patient history is important for diagnosing acne and identifying exacerbating factors. Key aspects include the onset, progression, lesion types (comedones, papules, pustules, nodules, cysts), and prior treatments (including outcomes and side-effects). Family history, lifestyle factors (diet, skincare, cosmetic use, stress, environmental triggers), and medication use should be reviewed. In female patients, assessing links between flare-ups and menstrual cycles can highlight hormonal influences.2,6,7
A detailed physical examination helps determine acne type, distribution, and severity. Lesions should be classified as non-inflammatory (open/closed comedones) or inflammatory (papules, pustules, nodules, cysts), with mapping of affected areas. Severity can be graded using tools like the Global Acne Grading System (GAGS) or Leeds Grading Technique. Evaluation for scarring, such as post-inflammatory hyperpigmentation, atrophic, hypertrophic, or keloidal scars, is also important.2,6,7
Laboratory tests are usually unnecessary for diagnosing acne vulgaris, but may be warranted in specific cases. In females with signs of hyperandrogenism, such as hirsutism or irregular menstrual cycles, hormonal tests (androgens, luteinising hormone, follicle stimulating hormone, prolactin) can help identify conditions like polycystic ovary syndrome.
Microbiological tests are rarely needed, but may rule out bacterial folliculitis or fungal infections if the diagnosis is uncertain. Skin biopsy is not routine, but can exclude other conditions in atypical cases.2,6,7
Management
The treatment and management of acne require a multifaceted approach that considers the type and severity of the condition, patient characteristics, and any underlying factors. Topical therapies are typically the first-line treatment for mild to moderate acne and can be combined with systemic therapies
for more severe cases.2
Topical retinoids are particularly effective as they normalise follicular keratinisation, promote cell turnover, and reduce comedone formation, addressing both inflammatory and non-inflammatory lesions. Benzoyl peroxide, an antimicrobial agent with anti-inflammatory properties, reduces C. acnes colonisation and is often used with topical antibiotics or retinoids to minimise antibiotic resistance.
Topical antibiotics help reduce bacterial load and inflammation, but are most effective when used alongside benzoyl peroxide to counter resistance. Azelaic acid, with its antibacterial, anti-inflammatory, and comedolytic effects, is especially useful for mild to moderate acne in individuals with sensitive skin. Salicylic acid, a beta-hydroxy acid, aids in exfoliating the skin and unclogging pores, making it particularly effective for comedonal acne.2,7,8,9
For moderate to severe acne, or cases unresponsive to topical treatments, systemic therapies are recommended.2 Oral antibiotics, such as lymecycline and doxycycline, are commonly prescribed for three-six months to reduce bacterial load and inflammation.8,9 Hormonal therapies, including oral contraceptives and anti-androgens, are effective for managing hormonal acne in female patients by regulating hormone levels, reducing sebum production, and mitigating androgen-driven effects on the skin.
Oral isotretinoin, a powerful retinoid, is reserved for severe, recalcitrant acne. It significantly reduces sebaceous gland size and sebum production, normalises keratinisation, and has anti-inflammatory properties. However, it requires careful monitoring due to potential side-effects, including teratogenicity. In certain severe or refractory cases, such as acne fulminans or acne conglobata, systemic corticosteroids or dapsone may be considered as additional treatment options.2,7
HSE antibiotic prescribing treatment guidelines for acne vulgaris are available at: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/conditions-and-treatments/skin-soft-tissue/acne-vulgaris/.
Adjunctive treatments can improve the effectiveness of acne therapies and address issues like scarring. Chemical peels with glycolic or salicylic acid help with comedonal acne and hyperpigmentation. Laser therapies, such as pulsed dye laser, intense pulsed light, and blue light, target C. acnes and inflammation, while fractional lasers improve scarring. Photodynamic therapy reduces sebaceous gland activity
and bacterial load, and microneedling promotes collagen production to enhance atrophic scars.2,7
While the role of diet remains debated, reducing high glycaemic index foods and limiting dairy may benefit some patients. Stress management through exercise or meditation can also help reduce acne flare-ups. Educating patients on their condition, treatment adherence, and skincare practices is important, along with addressing the emotional impact of acne and offering psychological support when needed.2,7
Research into new treatments for acne continues to evolve. Procedural treatments such as laser devices, photodynamic therapy, chemical peels, and intralesional injections present viable alternatives for reducing acne symptoms and scarring. Emerging therapies focus on novel biologics, bacteriophages, probiotics, and peptides, providing promising future options. The main aim is to create more individualised, effective, and sustainable acne management strategies that tackle the root causes of acne rather than just addressing its symptoms.10,11

ROSACEA
Rosacea is a chronic, multifactorial condition that is influenced by a range of factors. Genetic predisposition, along with triggers like microbial influences, ultraviolet (UV) exposure, diet, neurovascular changes, stress, and immune system dysfunction, can contribute to its development.12
Rosacea mainly affects the face, marked by transient or persistent redness, visible blood vessels (telangiectasia), and inflammatory lesions such as papules, pustules, and swelling. Contributing factors may include dysregulation of the immune system, vascular hyperreactivity, and the role of Demodex mites.
Environmental triggers such as UV light, heat, alcohol, and spicy foods often exacerbate symptoms. It affects up to 10 per cent of the world population, and is especially noted in fair-skinned individuals aged 35-50. Women are affected more often than men.12
Symptoms
Symptoms of rosacea vary depending on the subtype. Erythematotelangiectatic rosacea is characterised by persistent facial redness and visible blood vessels, while papulopustular rosacea presents with inflammatory papules and pustules that resemble acne. Phymatous rosacea causes thickening of the skin, most commonly on the nose (rhinophyma), while ocular rosacea can lead to eye symptoms such as dryness, irritation, and a sensation of burning or grittiness.12,13
Diagnosis
Diagnosis is based on clinical features, particularly the chronic central facial redness and the presence of papules or pustules without comedones, which distinguishes rosacea from acne. Subtypes may overlap in presentation. Diagnostic criteria for rosacea have been described as primary and secondary features. Primary features include flushing (transient erythema), non-transient erythema, papules and pustules, and telangiectasias.
Secondary features may include burning or stinging, plaques, a dry appearance, oedema, ocular manifestations, peripheral location, and phymatous changes. The presence of one or more primary feature is diagnostic, whereas secondary features are not necessarily present.13,14
Treatment and management
There is currently no cure for rosacea, but treatment can help control the symptoms. Management of rosacea begins with lifestyle modifications, including identifying and avoiding specific triggers. Sunscreen with a high sun protection factor (SPF) is important for protecting the skin from UV damage, which can exacerbate symptoms.
Treatment needs to be customised, and a combination of different modalities is often required for managing the variable signs and symptoms of rosacea.12,13 Although combination therapy is common practice and widely recommended, there is only limited evidence supporting its efficacy.13
Topical treatments such as metronidazole or azelaic acid are commonly prescribed for inflammatory lesions. The choice of topical agents is based on factors such as skin type, predominant signs and symptoms, mechanism of action, efficacy and tolerability of the drug, and past treatment. Vasoconstrictors may help reduce persistent redness by narrowing blood vessels.
Systemic therapies, including oral tetracyclines like doxycycline, are indicated for moderate to severe cases. Isotretinoin may be considered for refractory rosacea, although it is less commonly used than for acne. Specialist interventions, such as laser or intense pulsed light therapy, are effective for treating telangiectasia and persistent erythema. Ocular rosacea may require treatment with eyelid hygiene, artificial tears, and in severe cases, oral antibiotics or referral to an ophthalmologist.12,13,14
Patient education about rosacea and its triggers is important for comprehensive management.
People with rosacea have sensitive skin which flushes easily on exposure to sunlight or heat, alcohol consumption, and hot spicy foods. An individualised approach with regard to avoidance of trigger factors is needed, and patients should be advised about use of a high-SPF broad-spectrum sunscreen.12
Advances in understanding of rosacea’s pathophysiology have led to new topical treatments and the repurposing of therapies from other dermatological conditions. These innovations expand treatment options and may improve patient outcomes. However, while the goal is complete or near-complete clearance, many patients still fall short, even with adherence to current treatments.
As a result, more effective therapies, particularly combination treatments, are needed. Current treatments largely focus on erythema and papules/pustules, with ocular rosacea and phyma, especially during the early inflammatory stages, receiving less attention. Further advancements in both understanding and treating rosacea are required to meet the needs of all patients.13
ECZEMA (ATOPIC DERMATITIS)
Atopic dermatitis, or eczema, is a chronic inflammatory skin condition that affects more than 200 million people worldwide,15 and is the primary contributor to the global burden of skin diseases.16 The condition impacts individuals of all ages and backgrounds, and significantly affects the psychosocial wellbeing of patients. Its development is influenced by a compromised skin barrier, heightened immune cell activity within the skin and the composition of the skin’s microbiome.
A family history of atopic disease, particularly atopic dermatitis, is the strongest identifiable risk factor for developing the disorder. Mutations in the filaggrin gene can disrupt the skin barrier, leading to increased transepidermal water loss and heightened susceptibility to irritants and allergens.15,16
A variety of factors can exacerbate atopic dermatitis in affected individuals. These include irritants like wool fabrics and alkaline detergents, climatic conditions, infections, psychological stress, and, in sensitised patients, exposure to foods, inhalant allergens, or contact allergens.17
Symptoms
Symptoms of eczema include intense itching, redness, and dry, scaly patches of skin. In acute exacerbations, the skin may become swollen, oozing, and crusted. Chronic eczema can lead to lichenification, a thickened and leathery appearance of the skin due to repeated scratching.

The distribution of lesions varies with age. In infants, eczema often affects the face, scalp, and extensor surfaces, while in older children and adults, it more commonly involves flexural areas such as the elbows and knees. The condition is frequently associated with other atopic disorders, including asthma and allergic rhinitis.15,16
Diagnosis
Diagnosis is clinical and based on the characteristic appearance and distribution of the rash, along with a history of chronic or relapsing symptoms. Skin-prick testing or serum immunoglobulin (Ig) E levels may be helpful in identifying specific allergens that exacerbate the condition.17
When evaluating a patient with eczema, history should focus on the onset and distribution of lesions; severity of itching (eg, disrupting sleep); family or personal history of the atopic triad; and potential triggers such as allergens, hot showers, sweating, soaps, fragrances, food hypersensitivities, and synthetic fabrics.17
Physical findings vary by age. Infants typically present with oedematous papules and plaques, sometimes with vesicles or crusting, on the scalp, face, and extensor surfaces. In children, lesions appear as less exudative patches and plaques on the antecubital and popliteal fossae, while adults often develop chronic, lichenified lesions, particularly on the hands.
Lesions can be categorised as acute (erythematous papules, plaques, and crusting), subacute (erythema with scaling), or chronic (thickened plaques with lichenification and scaling).17
The differential diagnosis for atopic dermatitis includes several conditions. Allergic contact dermatitis should be considered, as it can present with similar skin findings. Lichen simplex and lichen planus are other possible diagnoses due to their inflammatory nature and distinct skin lesions.
Psoriasis, particularly in its early stages, may mimic atopic dermatitis. Scabies, a parasitic skin infestation, can also present with intense pruritus and rashes. Tinea, a fungal infection, should be ruled out, as well as seborrhoeic dermatitis, which can share overlapping features with atopic dermatitis.17
Management
Treatment and management focus on restoring the skin barrier, controlling inflammation, addressing triggers, and aims to improve symptoms and long-term disease control. Choice of anti-inflammatory therapy is largely based on disease severity.
Mild atopic dermatitis can usually be controlled with topical treatments, whereas more severe disease might require phototherapy, systemic immunomodulatory therapy, or both. Regular use of emollients is important for hydrating the skin and preventing flare-ups. Numerous studies show that bleach baths (diluted bleach) may help relieve the symptoms of atopic dermatitis by lowering the risk of superinfection with bacteria.17
Topical corticosteroids are the mainstay of treatment for reducing inflammation, with potency selected based on the severity and location of the lesions. Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, provide an alternative for sensitive areas like the face and eyelids or for long-term use.15,16,17
In cases of severe flares, short courses of oral corticosteroids may be required. For refractory eczema, systemic immunomodulators such as cyclosporine or methotrexate, or biologics like dupilumab, may be considered. Secondary bacterial infections, often caused by Staphylococcus aureus, should be treated with appropriate antibiotics. Patients should be educated on recognising early signs of flare-ups, maintaining adherence to treatment, and minimising exposure to known irritants or allergens.16,17,18
Further information on the treatment of eczema is available at: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/conditions-and-treatments/skin-soft-tissue/eczema/.
Conclusion
Each year, 54 per cent of the Irish population experiences skin problems, with up to 33 per cent requiring medical care at any given time. It is estimated that 15-20 per cent of general practice consultations are related to dermatological issues, accounting for approximately 712,500 to 950,000 visits annually in Ireland. While many skin conditions can be effectively managed in primary care, around 65,000 referrals are made each year to specialist dermatology departments for more complex cases.19
References
- Trakatelli M, Richard MA, Rouillard A, et al. The burden of skin disease in Europe. J Eur Acad Dermatol Venereol. 2023;37 Suppl 7:3-5.
- Sutaria AH, Masood S, Saleh HM, Schlessinger J. Acne vulgaris. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 17, 2023. Available at: www.ncbi.nlm.nih.gov/books/NBK459173/.
- Vasam M, Korutla S, Bohara RA. Acne vulgaris: A review of the pathophysiology, treatment, and recent nanotechnology based advances. Biochem Biophys Rep. 2023;36:101578.
- O’Neill A, Gallo R. Host-microbiome interactions and recent progress into understanding the biology of acne vulgaris. Microbiome. 2018;6(1):177.
- Reynolds R, Yeung H, Cheng C, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5).
- Tan A, Schlosser B, Paller A. A review of diagnosis and treatment of acne in adult female patients. Int J Women’s Dermatol. 2017;4(2):56-71.
- Oge L, Broussard A, Marshall M. Acne vulgaris: Diagnosis and treatment. Am Fam Physician. 2019;100(8):475-484.
- Health Service Executive. Acne treatment. Dublin: HSE; 2023.
Available at: www2.hse.ie/conditions/acne/treatment/. - Health Service Executive (HSE). Acne vulgaris – Antibiotic prescribing. Dublin: HSE; 2021. Available at: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/conditions-and-treatments/skin-soft-tissue/acne-vulgaris/.
- Tobiasz A, Nowicka D, Szepietowski J. Acne vulgaris – Novel treatment options and factors affecting therapy adherence: A narrative review. J Clin Med. 2022;11(24):7535.
- Kim H, Kim Y. Exploring acne treatments: From pathophysiological mechanisms to emerging therapies. Int J Mol Sci. 2024;25(10):5302.
- Sharma A, Kroumpouzos G, Kassir M, et al. Rosacea management: A comprehensive review. J Cosmet Dermatol. 2022;21(5):1895-1904.
- van Zuuren E, Arents B, van der Linden M, et al. Rosacea: New concepts in classification and treatment. Am J Clin Dermatol. 2021;22(4):457-465.
- Maden S. Rosacea: An overview of its etiological factors, pathogenesis, classification, and therapy options. Dermato. 2023;3(4):241-262.
- Chovatiya R. Atopic dermatitis (eczema). JAMA. 2023;329(3):268.
- Langan S, Irvine A, Weidinger S. Atopic dermatitis. Lancet. 2020;396(10247):345-360.
- Kolb L, Ferrer-Bruker SJ. Atopic Dermatitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available at: www.ncbi.nlm.nih.gov/books/NBK448071/.
- Health Service Executive (HSE). Infected eczema. Dublin: HSE; 2022. Available at: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/conditions-and-treatments/skin-soft-tissue/eczema/.
- Health Service Executive (HSE). National clinical programme for dermatology: A model of care for Ireland. Dublin: HSE; 2019.
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