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Azelaic acid

November 2022

Authors: Zena Al-Ani, The University of Auckland, New Zealand (2022)
Previous contributors: Dr Amanda Oakley Dermatologist, New Zealand (1999)
Reviewing dermatologist: Dr Ian Coulson

Edited by the DermNet content department


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What is azelaic acid?

Azelaic acid is a dicarboxylic acid molecule with anti-inflammatory and antioxidant properties, effective in the treatment of acne vulgaris and papulopustular rosacea, among other cutaneous conditions. 

Azelaic acid is a naturally occurring by-product of the metabolism of the yeast Malassezia furfur (also known as Pityrosporum ovale). In a number of countries, azelaic acid is available at a concentration of 20% as Skinoren™ cream, Acnederm™ lotion, and Azclear™ lotion. A 15% azelaic acid gel preparation was also approved for use in the US for rosacea, and a number of European countries for both rosacea and acne, eg, Finacea™ gel.

What is azelaic acid used for?

Azelaic acid is predominantly used as a topical treatment for mild to moderate acne, and may be combined with oral antibiotics or hormonal therapy. It is useful for both comedonal and inflammatory acne vulgaris.

Azelaic acid, a tyrosine inhibitor, also helps reduce pigmentation, therefore is particularly useful for darker skinned patients whose acne spots leave persistent brown marks (postinflammatory pigmentation) or who have melasma.

Although not registered in New Zealand for other skin disorders, azelaic acid products may also be useful in the treatment of:

What are the contraindications with azelaic acid?

  • Azelaic acid hypersensitivity, or hypersensitivity to any of the topical cream components (such as propylene glycol).

Tell me more about azelaic acid

Azelaic acid has the following properties: 

  • Antibacterial — it reduces the growth of bacteria in the follicle (eg, Cutibacterium acnes, also known as Proprionibacterium acnes; and Staphylococcus epidermidis) by inhibiting protein synthesis
  • Keratolytic and comedolytic — it improves the disordered growth of skin cells lining the follicle by inhibiting the proliferation and differentiation of human keratinocytes
  • Anti-inflammatory — reduces inflammation by scavenging free radicals; specifically, inhibits mitochondrial oxidoreductases and reduces the generation of pro‐inflammatory oxygen derivatives in neutrophils

Azelaic acid cream should be applied to the area affected by acne initially daily, then if tolerated building up to a generous twice-daily application after thoroughly cleansing the skin.

Acne responds slowly to treatment. Some improvement should be seen after one month of using azelaic acid cream. Further improvement should occur with maximum results after six months continuous use. Treatment may be continued safely for months or years if the acne remains active.

What are the benefits of azelaic acid?

Azelaic acid has both anti-inflammatory properties and targets hyperpigmentation. Its keratolytic properties means it is both exfoliative and comedolytic. It is a good option for acne treatment, with milder side-effects compared to more potent therapies. Some evidence suggests it is probably similarly effective to tretinoin for the treatment of acne.

Azelaic acid does not result in:

What are the disadvantages of azelaic acid?

  • Variable effect time, depending on the skin condition, severity, skin tone, and individual response to treatment.
  • People typically see an improvement in their acne after about four weeks of treatment. People being treated for rosacea might need to use this medication for up to 12 weeks before their skin starts to get better. 
  • May cause skin lightening (hypopigmentation) that is more apparent in darker skin tones.
  • Evidence suggests azelaic acid may be less effective for acne treatment than benzoyl peroxide when assessed using participants’ global self-assessment of acne improvement (PGA). 

What are the side effects and risks of azelaic acid?

Azelaic acid is nontoxic and is well tolerated by most subjects. However, those with very sensitive skin or who suffer from eczema may find it irritating to apply, resulting in a mild irritant contact dermatitis

Discontinue applying the cream and seek medical advice if you develop severe: 

  • Redness
  • Scaling
  • Itching
  • Burning.

Worsening of asthma has also been reported with azelaic acid treatment; consult a physician if asthma exacerbation occurs with use.

New Zealand approved datasheets are the official source of information for prescription medicines, including approved uses and risk information. Check the individual New Zealand datasheet on the Medsafe website.

If you are not based in New Zealand, we suggest you refer to your national drug approval agency for further information about medicines (eg, the Australian Therapeutic Goods Administration and the US Food and Drug Administration) or a national or state-approved formulary (eg, the New Zealand Formulary and New Zealand Formulary for Children and the British National Formulary and British National Formulary for Children).

 

Bibliography

  • Gupta AK, Gover MD. Azelaic acid (15% gel) in the treatment of acne rosacea. Int J Dermatol. 2007;46(5):533–8. doi:10.1111/j.1365-4632.2005.02769.x. Journal
  • Liu H, Yu H, Xia J, et al. Topical azelaic acid, salicylic acid, nicotinamide, sulphur, zinc and fruit acid (alpha-hydroxy acid) for acne. Cochrane Database Syst Rev. 2020;5(5):CD011368. doi:10.1002/14651858.CD011368.pub2. Review
  • Schulte BC, Wu W, Rosen T. Azelaic acid: Evidence-based update on mechanism of action and clinical application. J Drugs Dermatol. 2015;14(9):964–8. Journal
  • Singh SK, Chaubey S, Bansal A, Kaur G, Malik DS. Cosmeceutical aptitudes of azelaic acid. Curr Drug Res Rev. 2021;13(3):222–9. doi:10.2174/2589977513666210526122909. Journal

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