Azelaic Acid: What It Is, Benefits, Uses, Side Effects, and More

• Azelaic acid is an effective topical treatment for acne, rosacea, melasma and hyperpigmentation  
• It has antibacterial, anti-inflammatory and antikeratinizing properties
• This acid has exfoliating and antioxidant benefits to smooth and even out skin tone
• Some side effects include irritation, dry skin, tingling, itching and stinging

What Is Azelaic Acid?

Azelaic acid is a dicarboxylic acid compound that is derived from a type of yeast that is present on healthy skin, and is also found in wheat, rye and barley. A synthetic form is used in skin care products.

Topical applications such as creams, lotion and foams are formulated with this acid to effectively treat skin conditions such as mild-to-moderate acne, rosacea and hyperpigmentation. 

What does azelaic acid do for skin?

Azelaic acid addresses hyperpigmentation by decreasing melanin production, a natural pigment responsible for producing color in the skin. 

It effectively inhibits the production of keratin (a protein found in skin, nails and hair) which prevents the buildup of dead skin cells that can trigger acne breakouts. 

This acid can clear blocked pores, and as an antibacterial and anti-inflammatory, can soothe the irritation and redness caused by blemishes or rosacea. By encouraging cell turnover, it revitalizes skin and reduces the look of scarring.

Azelaic acid vs. AHA and BHA

When looking at benefits, azelaic acid can be compared to other chemical-based acids. Examples are alpha hydroxy acids (AHAs) which include glycolic acid and lactic acid, and beta hydroxy acids (BHAs), such as salicylic acid. There are some differences among the three but they do share similar traits.

Both AHAs and BHAs are very effective at exfoliating dead skin cells and debris from trapped pores. This exfoliation results in a smoother complexion and more even skin tone. However, while AHAs hasten the skin’s natural shedding process, BHAs penetrate deeper into the skin.

Azelaic acid is a milder treatment than either AHAs or BHAs and will therefore produce less dramatic results. However, as a gentler treatment, it results in fewer side effects and complications. It can also be layered with another treatment such as retinol—unlike AHAs and BHAs—as the combination would be too harsh on skin and cause irritation and dryness.

Azelaic acid has antibacterial and anti-inflammatory properties to effectively kill acne-causing bacteria, reduce inflammation and redness, and heal acne pimples and blackheads.

Salicylic acid is an anti-inflammatory that can slough off dead skin cells and target red, inflamed acne lesions, but it can do little to address bacteria – it is not an antibacterial.  

Azelaic Acid Benefits and Skin Care Uses

Azelaic acid is a skin care medication that offers strong benefits in treating acne, rosacea, melasma and hyperpigmentation. This cream can:

• Balance uneven skin tone 
• Calm sensitive skin
• Fade hyperpigmentation 
• Heal pustules and papules
• Kill bacteria on the skin’s surface
• Open pores and draw out debris
• Reduce redness
• Reduce skin inflammation

Acne

Azelaic acid is effective at acne treatment due to its antikeratinizing, anti-inflammatory and antibacterial properties.

As a keratolytic, it works to soften and break down the layers of dead skin cell buildup and debris that cause pimples and blackheads. This also prevents future acne breakouts by prompting cell turnover and removing excess oil on skin.

As an antibacterial, it can target acne-causing bacteria, reduce inflammation, redness and skin sensitivity.

Azelaic acid is a safe and proven acne treatment: In two studies, 20% azelaic acid cream was shown to be more effective than 0.05% tretinoin cream and better tolerated.

Hyperpigmentation

Azelaic acid can effectively treat postinflammatory hyperpigmentation – dark spots or patches on the skin that result from acne lesions, aging and prolonged sun exposure.

This acid is a tyrosinase inhibitor which interferes with melanin production. With time, dark cells are replaced by fresh new cells for a more even skin tone. 

Melasma

Like hyperpigmentation, melasma is a condition caused by an overproduction of melanin but it is usually the result of hormonal fluctuations or excessive exposure to the sun. It can also be exacerbated by sun and heat exposure, and is seen more often in people with dark skin due to a greater presence of melanin and melanosomes.

As an alternative to hydroquinone, a skin-lightening agent, azelaic acid is associated with a lower degree of irritation and dryness, which makes it a smart choice for those with dry, sensitive or eczema-prone skin.

Azelaic acid is also frequently combined with retinol and is considered a milder alternative to hydroquinone to manage hard-to-treat melasma.

While azelaic acid can reduce the appearance of hyperpigmentation, in darker skin, it could result in hypopigmentation, patches of skin that are lighter than the surrounding skin.  

Rosacea

Rosacea is a chronic skin condition that usually affects the face and causes redness, swelling and lesions. Azelaic acid’s anti-inflammatory properties have been shown to effectively treat these symptoms and is approved by the Food and Drug Administration (FDA) as a treatment for this condition.

As an antioxidant, this acid can neutralize the free radicals that damage skin cells and cause the inflammation associated with rosacea. It is considered a first-line treatment in killing Demodex mites, a common trigger of rosacea.

Azelaic Acid Products

Azelaic acid is found over the counter (OTC) and in prescription strength in several formulations, including foams, creams and gels. The most commonly prescribed brands are Azelex, Skinoren and Finacea.

The cream is available in strengths of 10–20%, gel in 10–15% and 15% for the low-concentration foam.

Foams are generally prescribed for larger areas such as the chest, while gels and creams are typically applied to the face and neck. Foams may also be prescribed for sensitive skin types as they are known to cause less stinging and irritation.

Prescription vs. OTC azelaic acid topicals

Your dermatologist will consider your skin type, condition and severity when choosing between an OTC or prescription medication.

Both OTC and prescription formulas are considered to be equally effective; one is not better than the other. However, it has been demonstrated that the gel tends to be more effective than a cream—even at a lower concentration—as they are more easily absorbed into the skin. 

How to Use Azelaic Acid

Azelaic acid can be used by itself or added to your skin care regimen. Your doctor will advise you to apply the product either once or twice a day. Before doing so, perform a patch test to determine if you have any sensitivities.

1. Wash your face with a gentle face wash and pat dry
2. Apply a thin layer of azelaic acid cream; avoid the eye area
3. Wash your hands well
4. Allow the medication to dry
5. Apply moisturizer and continue with your regular skin care routine 

To avoid further irritating your skin, do not overuse your medication and ensure you apply it sparingly. Avoid harsh alcohol-based cleansers or toners, or abrasive exfoliants as this could cause irritation and inflammation.

With proper application and consistent skin care, you should see results within 4-6 weeks.

Who should avoid using azelaic acid?

Avoid using azelaic acid if you are pregnant, thinking of becoming pregnant, or breastfeeding. If you have asthma or are prone to cold sores, speak with your doctor first before using this product. 

Azelaic acid could also cause hypopigmentation in those with darker skin tones and should therefore be used with caution.

Azelaic Acid Safety and Side Effects

Although it’s mild, azelaic acid can cause skin irritation, especially at first use. Side effects include skin sensitivity, dryness, tingling, burning, stinging, redness or peeling. More serious side effects can include blistering or flaking of skin, swelling, hives and itching, tightness of joints, fever or difficulty breathing.

Interactions

Due to its mild nature, azelaic acid can be combined with many other topical products such as retinoids, vitamin C and alpha hydroxy acids. In some cases, skin can develop sensitivity, therefore it is recommended to avoid alcohol-based cleansers or toners, and abrasive or peeling agents.

Azelaic Acid Alternatives

There are alternatives to azelaic acid but they usually must be combined with other treatments in order to achieve similar results.

Octadecenedioic acid, also a dicarboxylic acid compound, has antibacterial properties and is a skin lightener to effectively treat acne and hyperpigmentation.

Oral antibiotics such as tetracycline have strong anti-inflammatory and antimicrobial properties to target acne and rosacea. However, they are unable to treat hyperpigmentation.

Hydroquinone, a known skin-lightening agent, can successfully treat hyperpigmentation and melasma, but would need to be combined with other medications in order to manage rosacea or acne.

Takeaway

Azelaic acid is a multitasking compound that is highly effective in treating acne, rosacea, hyperpigmentation and melasma. This is due to its antioxidant, anti-inflammatory, antikeratinizing and antibacterial capabilities.

Treatments are available in gel, foam and cream formulas in both OTC and prescription strengths. Your doctor can determine which option would be best for you after assessing your skin type and the severity of your condition. 

For best results, follow all instructions and use your product consistently. If your symptoms remain or worsen, contact your doctor to discuss alternative treatments. 

Expected side effects include irritation, dry skin, tingling and itching. If these don’t resolve within a few days or if you experience more serious side effects, discontinue use and contact your doctor immediately.