Azelaic Acid for Acne: How it Works, Efficacy, Best Products, Side Effects

• Azelaic acid is an organic compound that has been approved by the Food and Drug Administration for topical use.
• This acid is best suited to treat mild-to-moderate acne breakouts. 
• This compound has antibacterial and anti-inflammatory properties to help reduce the inflammation, irritation and redness associated with acne.
• Side effects include irritation, dry skin, tingling, itching and stinging, and takes place within the first few days of use.

Unlike alpha hydroxy acids (AHAs) or beta hydroxy acids (BHAs) which are well known for their acne-fighting properties, azelaic acid is a dicarboxylic acid. This class of acids is used in skin care most commonly for their ability to kill the bacteria that causes acne and for other similar skin issues. This acid is especially beneficial for acne as it has exfoliative and anti-inflammatory properties.

What Is Azelaic Acid? 

Azelaic acid is a dicarboxylic acid produced as a byproduct of yeast that occurs naturally on the skin and in some grains such as wheat and rye. This acid can be extracted from these grains, converted to powdered form and formulated into a variety of skin care products. 

Usually this acid is added to topical gels, creams or foams. It can be included in smaller concentrations of 10% or less in over-the-counter (OTC) products, but it has also been approved for prescription products in concentrations up to 20%. 

This acid is valued within skin care products for its antibacterial, anti-inflammatory, antioxidant and exfoliative properties.  

How Does Azelaic Acid Help Treat Acne?

Azelaic acid is a chemical exfoliant that works to exfoliate in much the same way as other popular chemical exfoliants, such as glycolic acid. It removes the top layer of dead skin cells, promoting cell turnover and preventing blocked pores, which improves skin health and significantly decreases the likelihood of acne formation.  

This acid also suppresses keratin. Keratin is a protein found in skin, hair and nails. It serves a protective function, and is generally beneficial for skin, however, when too much keratin is produced it accumulates on the skin and blocks pores, contributing to acne. 

Can it treat active breakouts?

Yes, azelaic acid has been found to be just as effective as benzoyl peroxide and tretinoin in treating mild-to-moderate acne vulgaris and acne papules, and usually has a lower degree of irritation with minimal side effects.

Acne scarring and postinflammatory hyperpigmentation   

In addition to treating active acne, this acid can also help minimize acne scarring. It has been used as an alternative to hydroquinone for reducing dark spots caused by postinflammatory hyperpigmentation (PIH).

PIH is caused by the inflammation associated with acne. Inflammation triggers melanocytes to overproduce melanin in and around the inflamed area. This results in small, darkened patches of skin. 

Azelaic acid works to inhibit PIH by reducing the production of tyrosine, an amino acid. Because melanin is created by converting tyrosine, a reduction in that amino acid will prevent excess melanin from being produced.  

This acid can also reduce the visibility of acne scars through its exfoliating capabilities. By encouraging cell turnover through exfoliating, pigmented skin cells will be discarded faster, and the skin’s surface will become smoother and more even.

Best Azelaic Acid Products for Acne

Azelaic acid is often found as the primary active ingredient in gel, cream or foam formulations, and it can also be included in products with multiple active ingredients. All three forms have been proven to significantly reduce acne when properly applied, but you should still consider which form will be best tolerated by your skin. 

Azelaic acid foams and gels both contain many of the same ingredients. However some evidence suggests that acid foams are less irritating than gels (with both at 15% concentration), and therefore may be better suited to those with sensitive skin.

For those with dry skin, azelaic acid creams are available ranging from 10–20% concentrations and have emollient properties to help reduce dryness. For those with severe acne, peels in 30% concentrations can help reduce acne lesions and regulate sebaceous glands. 

Prescription vs. Over-the-Counter Azelaic Acid

There is no ideal percentage as to the best concentration of azelaic acid. Choosing between prescriptions with a higher concentration of this acid and OTC products depends on an individual’s skin type, the severity of their acne and their tolerance for this acid. 

Usually, a doctor-prescribed treatment will have 15% azelaic acid or more, while OTC options are typically 10% or less. Three common brand names for prescription products are Azelex, Skinoren and Finacea. 

While a higher concentration of this acid will usually be more effective in treating acne, it also depends on the product you choose. For example, an azelaic acid gel is better able to deliver the active ingredient to the skin than a cream, therefore a 15% gel may work just as well as a 20% cream. Essentially, users should be more concerned with choosing a formulation that is right for their skin. 

How to Use Azelaic Acid to Treat Acne

Before applying a product containing thos acid, do a small patch test. If there are no signs of irritation, apply a thin layer on the affected area, up to twice a day. Follow with a moisturizer suited to your skin type and during the day, a sunscreen with a minimum of 30 SPF.

For sensitive skin, apply it once every other day to determine if there is any discomfort. If you are using a prescription-based product, apply according to your prescription directions.

Since this acid can cause skin sensitivity, it’s best to avoid any alcohol-based cleansers or toners, as well as any products that may be abrasive to skin.

Azelaic acid results are slow to appear, so consistency in treatment is important. Some people could see results within 4-6 weeks; for others it can take up to three months. This acid is also commonly used with other acne treatments to improve results, so results will vary depending on this combined treatment.

For those with asthma, women who are pregnant or thinking of getting pregnant, it’s best to consult with a doctor before using azelaic acid.

Azelaic Acid Side Effects

Even though products with this acid is considered mild when compared to other acne-fighting ingredients such as benzoyl peroxide or retinoids, it can still cause discomfort for those with sensitive, rosacea or eczema-prone skin. 

Some common side effects are skin irritation, sensitivity, dryness, tingling or burning, redness, or flaking. Less common side effects include blistering or peeling of skin, swelling, hives and itching, tightness of joints, fever or difficulty breathing.

For those with darker skin tones, this acid could cause postinflammatory hypopigmentation. This occurs when the skin becomes inflamed, causing a decrease in melanin production and skin lightens as a result. 

If you experience these or any other serious side effects, discontinue use and  contact your doctor immediately.

Can azelaic acid cause breakouts? 

There are no conclusive studies that demonstrate this acid can cause breakouts. In some cases, the acid may cause additional irritation and dryness for those with eczema and rosacea, and some redness may occur. However, this would only be temporary. 

If you do start to experience additional breakouts, it’s best to speak with your doctor before continuing treatment.

Azelaic Acid vs. Other Acne Treatments 

Other acne-fighting treatments include AHAs such as glycolic and lactic acid, and BHAs, such as salicylic acid. As azelaic acid is considered a milder exfoliant, with little to no adverse reactions, the side effects are few, but the downside is that it’s not as effective and is slower to produce results.

One study found a combination gel of 3% benzoyl peroxide and 1% clindamycin to be more effective than a 20% azelaic acid cream. Further, while this study found both products were well tolerated, due to the high concentration of the acid, there were more adverse reactions. 

Can you combine azelaic acid with other acne-fighting ingredients?

Yes, azelaic acid is well tolerated by a variety of other ingredients, and often used in combination because it is gentle on skin. Studies show that this acid can be used in combination with benzoyl peroxide, tretinoin and clindamycin. 

It can also be used in combination with salicylic acid, where it has been shown to effectively treat inflammatory acne lesions. This combination produced results similar to a chemical peel used for acne treatment, but with less irritation.

Takeaway

Azelaic acid products are gentle on skin  and are effective in reducing acne. Its anti-inflammatory, antibacterial and antikeratinizing abilities exfoliate the skin, decrease the number of blocked pores and soothe active inflammatory lesions. 

This acid is best suited to treating mild-to-moderate acne, pimples, pustules and papules, but can be combined with other ingredients for a well rounded acne-fighting skin care routine. 

This acid also inhibits melanin formation and promotes fast cell turnover. This effectively reduces hyperpigmentation caused by acne scars and PIH. This acid is included in skin care products due to its multitasking abilities in the treatment of acne and acne-related symptoms.

Azelaic acid is a safe ingredient that most skin types react well to. It is included in various OTC creams and acne treatments, and is also available in prescription strength.