How Does Azelaic Acid Work?

Azelaic acid is an ingredient that is sometimes found in prescription and over-the-counter skin care products, and it is used to treat a variety of skin concerns. 

In Canada, azelaic acid is only approved as a prescription medication. How does azelaic acid work, what is it used for, and what are the common benefits and side effects?

What is azelaic acid?

Azelaic acid is an acidic chemical compound derived from certain grains, and it is an active ingredient in some topical skin care products. 

It is available as a prescription under the brand name Finacea, among others, in a 15-20% concentration, as well as at lower concentrations in some over-the-counter skin serums.1

The effectiveness of azelaic acid in lower concentrations in over-the-counter products is not as well-studied as that of prescription-strength azelaic acid products.

Finacea gel, which is a prescription topical treatment gel containing 15% azelaic acid, is FDA-approved for the treatment of inflammatory acne associated with mild-to-moderate rosacea.² 

Rosacea is a chronic inflammatory skin condition that may be associated with skin redness, flushing, and papular acne, often around the nose, cheeks, forehead, and chin.³ 

Azelaic acid may also be prescribed in addition to other treatments for certain skin concerns; for example, one study found that azelaic acid and benzoyl peroxide showed good results for the treatment of acne vulgaris.⁴ 

It is also prescribed off-label for the treatment of other skin concerns, particularly acne vulgaris, and melasma, which causes brown or grey patches on the face and other sun-exposed areas of the skin.^5,6 

Although azelaic acid is not FDA-approved for these conditions, a variety of studies suggest that it may be helpful in treating some skin concerns in some people.^5,7 

More research is needed to determine whether azelaic acid is an effective treatment for acne vulgaris, melasma, and other conditions.

How does azelaic acid work?

Azelaic acid works to treat rosacea-associated acne through a variety of mechanisms. 

Firstly, azelaic acid may inhibit the release of reactive oxygen species (ROS), which are small, unstable molecules formed through a variety of different biochemical reactions in the body.^8,9 

This may be beneficial in treating rosacea as ROS can induce a lot of stress on surrounding skin cells and tissues, and some research suggests that they may be associated with the pathogenesis of rosacea.⁸ 

Azelaic acid may also work through its anti-inflammatory properties, which could potentially help reduce the severity of rosacea; however, the mechanism of action for this is unknown.^7,8

Some research suggests that azelaic acid is bactericidal against anaerobic Propionibacterium acnes, which is a bacteria thought to be related to the development of acne vulgaris.^10,11 

This, together with its other properties, could potentially make azelaic acid an effective treatment for acne vulgaris in some people; however, more research is needed to confirm this.

The relationship between melasma and azelaic acid therapy is also not completely known; however, some research suggests that azelaic acid may work to inhibit the activity and replication of abnormally-acting melanocytes, which are cells that form melanin.⁵ 

Azelaic acid seems to selectively inhibit abnormally-growing melanocytes; the current research suggests that azelaic acid does not reduce or alter the pigmentation of normal skin cells and freckles.¹² 

More research is needed to determine whether azelaic acid is an effective treatment for melasma.

Side effects of azelaic acid

Azelaic acid may be appealing to some individuals because it does not have the same side effects as some treatments, such as antibiotic resistance from long-term antibiotic use for acne.¹¹ 

Some common side effects may include skin irritation and redness, which usually resolves after a few weeks of use.

Another potential side effect of azelaic acid treatment is hypopigmentation or lightening of the skin.¹³ Although current research suggests that azelaic acid is safe for individuals with darker skin tones, more research is needed to ensure its safety as well as reduce the risk of this potential side effect.¹⁴ 

Azelaic acid is classified under Pregnancy Category B, which means that animal studies have not indicated a risk to a developing fetus and there is not enough research from studies with pregnant women.^15,16 

Although no teratogenic effects were found in animal studies, there is not enough research to guarantee that it is safe during pregnancy.¹⁵

It is important to tell your doctor about any side effects you are concerned about when using azelaic acid; they may want to alter the strength of the prescription or discontinue it altogether. 

Seek medical help immediately if you experience signs of an allergic reaction after using the medication, such as hives, chest tightness, or swelling of the face, mouth, or throat.

Azelaic acid may interact with some skincare products as well as some oral and topical medications, so it is important to tell your doctor about all products, supplements, medications, and skincare products that you are using. 

This article is not medical advice, and it is not intended to prescribe, diagnose, or promote specific treatments for any condition.

Consult your doctor, dermatologist, or other qualified healthcare provider for your unique skin needs.

References

1. RxList Professional (2020, December 10). Finacea. RxList online. Accessed 2021, May 24, from https://www.rxlist.com/script/main/hp.asp
2. FDA Access Data (2010, July). Finacea (azelaic acid) Gel 15%. Intendis: Bayer. Accessed 2021, May 24, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021470s005lbl.pdf
3. Farschian, M., Daveluy, S. (2021, January 16). Rosacea. StatPearls [Internet]. Accessed 2021, May 24, from https://www.ncbi.nlm.nih.gov/books/NBK557574/
4. Webster, G. (2000, August). Combination azelaic acid therapy for acne vulgaris. Journal of the American Academy of Dermatology 43(2:3): S47-50. Doi: 10.1067/mjd.2000.108318
5. Fitton, A., Goa, K.L. (1991). Azelaic Acid: A review of its pharmacological properties and therapeutic efficacy in acne and hyperpigmentary skin disorders.
6. American Academy of Dermatology Association (n.d.) Melasma: Overview. American Academy of Dermatology. Accessed 2021, May 24, from https://www.aad.org/public/diseases/a-z/melasma-overview
7. Sieber, M.A., Hegel, J.K.E. (2014). Azelaic acid: properties and mode of action. Skin Pharmacol Physiol 27(suppl 1): 9-17. Doi: 10.1159/000354888
8. Jones, D.A (2009, January). Rosacea, reactive oxygen species, and azelaic acid. J Clin Aesthet Dermatol 2(1): 26-30. Accessed 2021, May 24, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958186/
9. Akamatsu, H., Komura, J., Asada, Y., et al (1991). Inhibitory effect of azelaic acid on neutrophil functions: a possible cause for its efficacy in treating pathogenetically unrelated diseases. Arch Dermatol Res 283(3): 163-166. Doi: 10.1007/BF00372056.
10. Bojar, R.A., Holland, K.T., Cunliffe, W.J., et al (1991, December). The in-vitro antimicrobial effects of azelaic acid upon Propionibacterium acnes strain P37. J Antimicrob Chemother 28(6): 843-853. Doi: 10.1093/jac.28.6.843
11. Nazzaro-Porro, M., Passi, S., Picardo, M., et al (1989, April). Azelaic acid in the treatment of acne. G Ital Dermatol Venereol 124(4): 175-184. Accessed 2021, May 24, from https://pubmed.ncbi.nlm.nih.gov/2530163/
12. Nielsen, C., Hsu, S., Motaparthi, J. (2021). 41- Topical Antibacterial Agents. Comprehensive Dermatologic Drug Therapy (Fourth Edition). 465-479.e9. Doi: 10.1016/B978-0-323-61211-1.00041-3
13. Grobel, H., Murphy, S.A. (2018). Chapter 77-Acne Vulgaris and Acne Rosacea. Integrative Medicine (Fourth Edition): 759-770.e5. Doi: 10.1016/B978-0-323-35868-2.00077-3
14. Lowe, N.J., Rizk, D., Grimes, P., et al (1998). Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther 20(5): 945-959. Doi: 10.1016/s0149-2918(98)80076-3.
15. Gupta, A.K., Gover, M.D. (2007, April). Azelaic acid (15% gel) in the treatment of acne rosacea. International Journal of Dermatology 46(5): 533-538. Doi: 10.1111/j.1365-4632.2005.02769.x
16. Chemical Hazards Emergency Medical Management. (2021, March 8). FDA Pregnancy Categories. U.S. Department of Health & Human Services. Accessed 2021, May 24, from https://chemm.nlm.nih.gov/pregnancycategories.htm
17. Image by Engin Akyurt from Pixabay