Medication - Azelaic Acid

This article will address frequently asked patient questions about Azelaic Acid, its uses for treating acne, hyperpigmentation, and other skin concerns.

Azelaic Acid

What is Azelaic Acid and how does it work?

Azelaic acid is a naturally occurring acid found in grains like barley, rye, and wheat. It is often used in skincare treatments for its unique ability to reduce acne, hyperpigmentation, and rosacea. Azelaic acid works by targeting several processes in the skin:

• Reduces bacteria: It kills the bacteria on the skin that cause acne, specifically Cutibacterium acnes.

• Decreases inflammation: Azelaic acid has anti-inflammatory properties that reduce redness and swelling, making it ideal for inflammatory conditions like acne and rosacea.

• Blocks melanin production: It inhibits an enzyme called tyrosinase, which helps to decrease melanin production. This is why it’s effective in treating hyperpigmentation conditions such as melasma and post-inflammatory hyperpigmentation (PIH).

This multi-targeted approach makes azelaic acid useful in treating a range of skin conditions, and it’s generally well-tolerated even by people with sensitive skin.

What conditions can Azelaic Acid treat?

Azelaic acid is versatile and can treat several skin concerns, including:

• Acne: It treats mild to moderate acne by killing bacteria, reducing inflammation, and preventing clogged pores.

• Rosacea: For people with rosacea, it helps to reduce redness and swelling.

• Hyperpigmentation: Azelaic acid can lighten dark spots caused by sun damage, melasma, and post-inflammatory hyperpigmentation.

• Post-inflammatory hyperpigmentation (PIH): This is common after acne or skin injuries and is characterized by dark spots.

Because of its anti-inflammatory, antibacterial, and melanin-inhibiting properties, azelaic acid is a great all-around treatment for various skin issues.

How does Azelaic Acid compare to other treatments for hyperpigmentation?

When compared to other treatments like hydroquinone, azelaic acid offers a gentler option for treating hyperpigmentation. Hydroquinone is often considered the gold standard for lightening dark spots, but it can cause skin irritation and isn’t suitable for long-term use. Azelaic acid, on the other hand, is safe for longer-term use and is less likely to cause irritation or unwanted side effects like ochronosis (a rare skin discoloration from hydroquinone). Studies have shown that azelaic acid can be just as effective in treating hyperpigmentation as hydroquinone but with a safer profile for people with sensitive or darker skin tones.

Can Azelaic Acid be used to treat melasma?

Yes, azelaic acid is commonly used to treat melasma, a condition where dark patches form on the skin, often due to hormonal changes or sun exposure. By inhibiting the enzyme tyrosinase, azelaic acid reduces the production of melanin, which helps lighten the dark patches associated with melasma. It is a safer alternative to hydroquinone, especially for long-term use, as it carries fewer risks of irritation and discoloration. While it may take a few months to see noticeable results, consistent use can make a significant difference in reducing melasma.

Is Azelaic Acid suitable for all skin types?

Yes, azelaic acid is suitable for all skin types, including sensitive, oily, dry, and combination skin. It’s particularly good for those with sensitive skin because it is less likely to cause irritation compared to stronger treatments like retinoids or chemical exfoliants. It also works well on darker skin tones and is less likely to cause skin lightening or irritation, which can sometimes happen with treatments like hydroquinone. Azelaic acid’s gentleness makes it ideal for people looking for effective results without the harsh side effects.

How does Azelaic Acid help with acne?

Azelaic acid is an effective treatment for acne due to its ability to target multiple factors that cause breakouts:

• Kills bacteria: It targets the bacteria (Cutibacterium acnes) that live on the skin and cause acne.

• Reduces inflammation: The anti-inflammatory effects of azelaic acid help reduce the redness and swelling associated with acne.

• Prevents clogged pores: Azelaic acid helps normalize the shedding of dead skin cells, which reduces the chance of pores becoming clogged, thus preventing the formation of new acne lesions. These combined actions make azelaic acid a powerful tool in controlling mild to moderate acne while reducing the likelihood of scarring and post-acne marks

What are the different forms of Azelaic Acid available (gel, cream, foam)?

Azelaic acid comes in different forms to suit different skin needs and preferences:

• Gel: Usually found in a 15% concentration, gels are lightweight and absorb quickly, making them ideal for treating acne-prone skin.

• Cream: Creams are available in concentrations from 10-20%. They tend to be more hydrating and are commonly used for treating hyperpigmentation and rosacea.

How long does it take to see results from Azelaic Acid?

You can typically start seeing results from azelaic acid after 4 to 6 weeks of consistent use, but it may take up to 12 weeks to see full improvement, particularly for more stubborn issues like melasma or rosacea. It’s important to apply azelaic acid regularly and be patient, as it works gradually over time. For acne, improvements in the number of breakouts and overall skin texture can often be seen in the first few weeks.

Can Azelaic Acid be used on sensitive skin?

Yes, azelaic acid is one of the best treatments for sensitive skin. It’s much gentler than other common acne or pigmentation treatments like retinoids, hydroquinone, or benzoyl peroxide. If irritation does occur, it’s usually mild and can be managed by using it less frequently at first and then gradually increasing use. Because azelaic acid has anti-inflammatory properties, it can even help calm down sensitive skin prone to redness or rosacea.

How does Azelaic Acid help with post-inflammatory hyperpigmentation (PIH)?

Azelaic acid is highly effective in treating post-inflammatory hyperpigmentation (PIH), which are dark spots left behind after acne or injuries. It works by inhibiting melanin production, which helps lighten the dark spots and prevent new ones from forming. Over time, azelaic acid promotes an even skin tone by reducing the appearance of PIH. It is a safer option for treating hyperpigmentation in people with darker skin tones, as it carries a lower risk of causing skin lightening or irritation compared to other treatments like hydroquinone.

Azelaic Acid and Acne

Is Azelaic Acid effective in treating acne scars?

Azelaic acid is effective in reducing post-inflammatory hyperpigmentation (PIH), which are dark spots left behind after acne heals. While it doesn’t directly treat pitted or depressed acne scars, its ability to inhibit melanin production can help fade acne scars related to pigmentation. Studies show that azelaic acid, particularly in a 20% concentration, is effective for reducing PIH and promoting a more even skin tone​.

How does Azelaic Acid compare to benzoyl peroxide or salicylic acid for acne?

Azelaic acid is generally gentler than benzoyl peroxide or salicylic acid, making it a good option for people with sensitive skin. Benzoyl peroxide is often more effective for quickly killing acne-causing bacteria, while salicylic acid excels at exfoliating and clearing out pores. Azelaic acid, however, offers anti-inflammatory, anti-microbial, and skin-brightening properties, making it a versatile option that treats both active acne and pigmentation issues. While it may not be as fast-acting as benzoyl peroxide, it’s a good long-term solution with fewer side effects like dryness and irritation.

Can Azelaic Acid prevent future acne breakouts?

Yes, azelaic acid helps prevent future breakouts by normalizing keratinization, which is the process where skin cells shed. By keeping pores from getting clogged and killing acne-causing bacteria (Propionibacterium acnes), azelaic acid can help reduce the occurrence of new acne lesions.

Does Azelaic Acid help with blackheads or whiteheads?

Azelaic acid can help with whiteheads, as it works by reducing bacterial growth and unclogging pores. It does also help with blackheads. However, for blackheads, which are a result of oxidized sebum, it may not be as effective as salicylic acid, which penetrates and clears out blocked pores more efficiently​.

Can you use Azelaic Acid with other acne treatments?

Yes, azelaic acid can be combined with other acne treatments. It is often used alongside topical retinoids or antibiotics for more severe acne cases. Studies suggest that it can be safely combined with clindamycin or erythromycin to enhance its effects, particularly for inflammatory acne​. However, care should be taken when combining with strong exfoliants like AHAs (i.e. glycolic acid) or BHAs to avoid irritation.

How should Azelaic Acid be applied in a skincare routine for acne?

Azelaic acid should be applied after cleansing and before moisturizing. For optimal results, it can be used once or twice daily, depending on tolerance. It’s important to start with a lower concentration and gradually increase usage to avoid irritation. Follow it with a moisturizer and sunscreen during the day.

Does Azelaic Acid reduce oil production in the skin?

Azelaic acid doesn’t have a direct effect on sebum (oil) production, unlike treatments such as retinoids or oral medications like isotretinoin. However, by reducing clogged pores and controlling acne-causing bacteria, it can help manage the effects of excess oil without altering oil production itself. Salicylic acid is a preferred agent to reduce sebum production.

Can Azelaic Acid be used on body acne?

Yes, azelaic acid can be used on body acne, particularly on areas like the chest, back, and shoulders. While most formulations are intended for facial use, azelaic acid’s anti-inflammatory and anti-microbial properties can also benefit body acne, helping to clear breakouts and prevent post-acne marks.

What concentration of Azelaic Acid is recommended for acne treatment?

For acne treatment, 15% to 20% concentrations of azelaic acid are recommended. The 15% gel is often prescribed for rosacea and mild acne, while the 20% cream is used more frequently for treating acne and hyperpigmentation.

Using Azelaic Acid

What is the recommended dosage of Azelaic Acid for treating acne or pigmentation?

The recommended dosage of azelaic acid depends on the concentration and formulation. For acne, a 15% gel or 20% cream is commonly used. The typical application involves using a pea-sized amount of the product once or twice daily, applied evenly across the affected areas.

How should Azelaic Acid be used in a skincare routine?

Azelaic acid should be applied after cleansing and before moisturizing. A typical skincare routine would follow this order:

1. Cleanser: Wash your face with a gentle cleanser.

2. Azelaic acid: Apply a pea-sized amount of azelaic acid to affected areas, usually once or twice daily, depending on tolerance.

3. Moisturizer: Use a moisturizer to help hydrate and soothe the skin.

4. Sunscreen (in the morning): Apply broad-spectrum sunscreen during the day to protect your skin.

Can I use Azelaic Acid every day?

Yes, azelaic acid can generally be used every day, even twice daily, depending on how your skin reacts to it. For beginners, it’s best to start with once-daily use and gradually increase to twice a day if your skin tolerates it well. Azelaic acid is relatively mild and is less likely to cause irritation compared to other acne or pigmentation treatments like retinoids.

How long should I leave Azelaic Acid on my skin?

Azelaic acid should be left on the skin after application and not washed off. It is a leave-on treatment designed to absorb into the skin and work throughout the day or night. After applying azelaic acid, follow it up with a moisturizer and sunscreen during the day​.

Should Azelaic Acid be used before or after moisturizer?

Azelaic acid should be used before applying a moisturizer. Apply it directly onto cleansed skin so it can fully absorb, and then follow with a moisturizer to lock in hydration and minimize any potential dryness or irritation that azelaic acid might cause.

Can Azelaic Acid be used under makeup?

Yes, azelaic acid can be used under makeup. It absorbs into the skin and does not interfere with the application of makeup. However, it’s important to let the azelaic acid fully dry and absorb before applying any makeup products. Follow it with a primer or a light moisturizer if needed.

What is the best time of day to use Azelaic Acid?

Azelaic acid can be used both in the morning and at night. If applying in the morning, make sure to follow it with a broad-spectrum sunscreen.

How should I store Azelaic Acid products to maintain their effectiveness?

Azelaic acid products should be stored in a cool, dry place away from direct sunlight to maintain their effectiveness. Excessive heat or exposure to light can degrade the active ingredients in the product, reducing its potency. Make sure the cap is tightly sealed after each use​.

Can Azelaic Acid be used during pregnancy or breastfeeding?

Yes, azelaic acid is considered safe to use during pregnancy and breastfeeding. It is classified as a Category B medication, meaning that studies in animals have shown no harm to the fetus, but there are limited studies in pregnant women. It’s commonly recommended for women dealing with acne or pigmentation issues during pregnancy, but always consult with your healthcare provider before starting any new treatment​.

Is it safe to use Azelaic Acid around the eyes or mouth?

Azelaic acid can be applied to the face, but it should be used cautiously around sensitive areas like the eyes and mouth. Avoid direct contact with these areas, as azelaic acid may cause stinging or irritation if it gets into the eyes or mucous membranes.

Side Effects and Concerns

What are the potential side effects of using Azelaic Acid?

Azelaic acid is generally well-tolerated, but some users may experience mild side effects. Common side effects include:

• Mild irritation (stinging or burning)

• Dryness

• Redness

• Peeling These side effects are often temporary and tend to subside as the skin adjusts to the product. More serious side effects, such as swelling, blistering, or severe irritation, are rare​.

What should I do if Azelaic Acid causes irritation or dryness?

If irritation or dryness occurs, try reducing the frequency of application. Start by using azelaic acid once a day or every other day, and gradually increase use as your skin becomes more tolerant. You can also apply a moisturizer after the azelaic acid to help soothe the skin and minimize dryness.

Can Azelaic Acid cause peeling or redness?

Yes, azelaic acid can cause peeling and redness, especially in the early stages of use. This is more common in individuals with sensitive skin. These effects usually subside after a few weeks of consistent use as the skin adapts to the treatment​.

Is Azelaic Acid safe for long-term use?

Azelaic acid has been shown to be safe for long-term use in clinical trials lasting up to 12 months. Studies support its effectiveness and tolerability when used continuously during this period without significant adverse effects. However, data on continuous use beyond 12 months is limited. While extended studies are lacking, dermatologists often recommend intermittent use for managing flares of conditions like rosacea and acne​.

For chronic conditions, it is common to use azelaic acid during flare-ups and then taper off or switch to other maintenance treatments​

Does Azelaic Acid increase sensitivity to the sun?

Azelaic acid does not significantly increase sun sensitivity compared to treatments like retinoids or benzoyl peroxide, but it is still advisable to use sunscreen when applying azelaic acid, especially during the day. Sunscreen will protect your skin and prevent further hyperpigmentation​.

Can Azelaic Acid be used alongside retinoids or AHAs?

Yes, azelaic acid can be used with retinoids or alpha-hydroxy acids (AHAs), but caution is advised as these treatments can increase the risk of irritation. It’s best to alternate use (e.g., using azelaic acid in the morning and retinoids or AHAs at night) to minimize irritation. Always start with lower concentrations and monitor your skin’s response​.

Should I stop using Azelaic Acid if I experience burning or stinging?

If you experience mild burning or stinging, try reducing the frequency of application or applying it alongside a moisturizer to minimize irritation. If the burning is severe or persists for more than a few days, it’s best to discontinue use and consult a doctor.

Is there a risk of developing resistance to Azelaic Acid?

There is no evidence that bacteria develop resistance to azelaic acid, unlike some topical antibiotics used to treat acne. Azelaic acid has a different mechanism of action, which involves reducing bacterial growth and inflammation, making it a safe long-term option without the concern of resistance.

Can Azelaic Acid cause discoloration or worsening of hyperpigmentation?

In rare cases, azelaic acid may cause temporary lightening of the skin, particularly in individuals with darker skin tones. However, it is generally effective at reducing hyperpigmentation rather than worsening it.

Comparison to Other Treatments

How does Azelaic Acid compare to hydroquinone for treating pigmentation?

Azelaic acid and hydroquinone are both effective treatments for hyperpigmentation, but they work in different ways. Hydroquinone is a strong depigmenting agent that directly inhibits melanin production by targeting melanocytes. It is often more potent and can produce faster results, but it also carries risks such as skin irritation, ochronosis (a condition causing dark patches), and is not recommended for long-term use. Azelaic acid, on the other hand, is gentler and inhibits melanin production indirectly by blocking the enzyme tyrosinase. While azelaic acid may take longer to show results compared to hydroquinone, it is safer for long-term use and is suitable for sensitive or darker skin tones, as it is less likely to cause side effects​.

What are the advantages of using Azelaic Acid over tretinoin or other retinoids?

Azelaic acid is generally better tolerated than retinoids like tretinoin, making it a good choice for individuals with sensitive skin or those who cannot tolerate the peeling, dryness, and irritation that retinoids often cause. Unlike retinoids, which primarily work by speeding up cell turnover, azelaic acid has anti-inflammatory and antibacterial properties, making it more effective for treating acne and rosacea while also addressing pigmentation issues. Retinoids, however, are stronger for reducing fine lines and boosting collagen production​.

Can Azelaic Acid be used with exfoliating acids like glycolic acid?

Yes, azelaic acid can be used with glycolic acid and other exfoliating acids like lactic acid or mandelic acid, but caution is advised. Combining multiple acids can increase the risk of irritation, especially for sensitive skin. If using both, it’s best to alternate their application (e.g., using azelaic acid in the morning and glycolic acid at night) or start with lower concentrations and gradually build up tolerance.

Is Azelaic Acid better than niacinamide for reducing redness and hyperpigmentation?

Both azelaic acid and niacinamide are effective for reducing redness and hyperpigmentation, but they work differently. They can be used together. Azelaic acid is more targeted for reducing melanin production and treating post-inflammatory hyperpigmentation (PIH) due to its direct action on tyrosinase. It is also more effective in treating acne and rosacea due to its antibacterial and anti-inflammatory properties. Niacinamide, on the other hand, is gentler and is known for its ability to strengthen the skin barrier, reduce oil production, and calm inflammation, making it better suited for long-term use without irritation

How does Azelaic Acid compare to tranexamic acid in treating pigmentation?

Tranexamic acid and azelaic acid both treat pigmentation, but tranexamic acid specifically targets melasma by reducing blood vessel formation in the skin and interfering with UV-induced pigment production. It works through a different mechanism than azelaic acid, which inhibits tyrosinase and reduces inflammation. While tranexamic acid is emerging as a potent treatment for melasma, azelaic acid offers the added benefits of treating acne and rosacea, making it a more versatile option. Both can be combined for improved results.

Is Azelaic Acid better suited for sensitive skin than stronger treatments like retinoids?

Yes, azelaic acid is better suited for sensitive skin compared to stronger treatments like retinoids. Azelaic acid is non-irritating for most skin types and is less likely to cause peeling or redness. Retinoids, while powerful, often lead to dryness and irritation, especially in those with sensitive skin or conditions like rosacea. Azelaic acid’s gentler action makes it ideal for long-term use without the risk of over-exfoliating or damaging the skin barrier.

How does Azelaic Acid differ from natural remedies like kojic acid or arbutin?

Kojic acid and arbutin are both natural skin lighteners that work by inhibiting tyrosinase, much like azelaic acid. However, azelaic acid has the added benefits of being anti-inflammatory and antibacterial, making it more effective for treating acne and conditions like rosacea in addition to pigmentation. Kojic acid can be irritating to the skin and is less stable, while arbutin is generally milder but slower in producing visible results. Azelaic acid offers a broader range of benefits and is backed by more robust clinical evidence.

What makes Azelaic Acid different from other acne treatments like isotretinoin?

Isotretinoin (commonly known as Accutane) is a powerful oral medication for severe acne that works by shrinking the oil glands in the skin and reducing sebum production. It’s reserved for severe, cystic acne and comes with potential side effects such as dryness, sensitivity, and teratogenic risks (birth defects). Azelaic acid, on the other hand, is a topical treatment suitable for mild to moderate acne. It targets bacteria and inflammation but doesn’t affect sebum production, making it gentler and safer for long-term use without systemic side effects​.

Is Azelaic Acid more effective than chemical peels or laser treatments for pigmentation?

Azelaic acid is a good option for long-term management of pigmentation, but it is not as fast-acting as chemical peels or laser treatments. Chemical peels like TCA or glycolic acid and laser treatments can provide immediate and dramatic results by exfoliating the upper layers of the skin or targeting pigmentation at a deeper level. However, these procedures come with downtime, risks of irritation, and potential for post-inflammatory hyperpigmentation. Azelaic acid is safer for gradual, long-term use and is less likely to cause irritation or worsening pigmentation.

What is the difference between Azelaic Acid and chemical exfoliants like salicylic acid?

Azelaic acid primarily works as an anti-inflammatory, antibacterial, and tyrosinase-inhibiting agent, making it ideal for treating acne, pigmentation, and rosacea. Salicylic acid, on the other hand, is a chemical exfoliant that is oil-soluble, meaning it penetrates deeply into the pores to clear out sebum and dead skin cells. While both can help with acne, salicylic acid is more effective for treating blackheads and whiteheads, whereas azelaic acid is better suited for inflammatory acne and pigmentation concerns.

Long-Term Use and Maintenance of Azelaic Acid

Can I use Azelaic Acid for maintenance after my skin clears?

Yes, azelaic acid is commonly used for maintenance after achieving clear skin. Its gentle nature and effectiveness at controlling acne, rosacea, and pigmentation make it ideal for long-term use to prevent new breakouts and keep pigmentation issues at bay. Many dermatologists recommend continuing azelaic acid to maintain skin clarity and prevent flare-ups​.

Will Azelaic Acid lose its effectiveness over time?

Azelaic acid does not typically lose its effectiveness over time. Unlike antibiotics, where bacteria can develop resistance, azelaic acid works through anti-inflammatory and antibacterial mechanisms that remain effective with prolonged use. This makes it a reliable option for long-term management of skin conditions such as acne, rosacea, and hyperpigmentation.

How often should I use Azelaic Acid for long-term pigmentation management?

For long-term management of pigmentation, azelaic acid can be used once or twice daily, depending on skin tolerance. Some patients find that using it daily for maintenance is sufficient, while others may use it less frequently, such as every other day, after achieving significant improvement. Consistency is key to preventing the reappearance of hyperpigmentation.

Can I stop using Azelaic Acid once my skin improves?

While you can stop using azelaic acid once your skin improves, it is often recommended to continue using it for maintenance. Discontinuing treatment may lead to a recurrence of acne or pigmentation issues, as the underlying causes (such as bacteria or overproduction of melanin) may still be present.

For long-term use (i.e. years or indefinitely), it is generally considered safe because azelaic acid does not cause the typical issues associated with stronger treatments (like skin thinning with corticosteroids or resistance with antibiotics).

Many dermatologists commonly recommend using it on an ongoing basis for maintenance after the initial improvement.

Will stopping Azelaic Acid cause a return of pigmentation or acne?

Yes, stopping azelaic acid can cause a return of pigmentation or acne, particularly if the skin condition is chronic or persistent. Azelaic acid helps manage these conditions, but once treatment stops, the factors contributing to them (such as inflammation or excess melanin production) can reoccur.

Does Azelaic Acid help prevent acne scars in the long run?

Azelaic acid can help reduce the risk of post-inflammatory hyperpigmentation (PIH), a type of acne scar caused by pigmentation changes. Its ability to prevent excessive melanin production and reduce inflammation makes it effective in minimizing the formation of dark spots after acne heals. However, it is not effective at treating or preventing textured or pitted acne scars.

What happens if I use too much Azelaic Acid at once?

Using too much azelaic acid at once can result in increased irritation, such as burning, stinging, or redness. If you apply more than the recommended amount, wash your face with water to remove the excess product. In the future, stick to the recommended dosage, which is usually a pea-sized amount for each application.

Is there a need to adjust the concentration of Azelaic Acid over time?

There is generally no need to adjust the concentration of azelaic acid over time. Most studies support the use of 15% to 20% concentrations, which are effective for long-term treatment of acne, rosacea, and pigmentation issues. If your skin becomes overly sensitive or irritated, you may need to reduce the frequency of application rather than switching concentrations.

Can Azelaic Acid be used in winter when skin is drier?

Yes, azelaic acid can be used during the winter, but you should pair it with a moisturizer to prevent dryness, which is more common in colder months. Using a rich, hydrating moisturizer can help counteract any dryness or irritation caused by the drier climate, allowing you to continue benefiting from azelaic acid’s effects throughout the year​.