Azelaic Acid: The Underrated Multitasker
Last week we talked about hydroquinone, the powerful but high-maintenance gold standard for dark spots. This week's ingredient is its gentler cousin, and honestly one of my favorites: azelaic acid. It doesn't get the hype that retinol or vitamin C gets, but the research behind it is impressive, and it does several jobs at once.
What azelaic acid is
Azelaic acid is a natural acid produced by a yeast that already lives on human skin, and it's also found in grains like wheat and barley. Skincare products use a lab-made version so it's pure and consistent.
What it does in the skin
Fades pigment. Like hydroquinone, it blocks tyrosinase, the enzyme that makes melanin, but more gently.
Fights acne bacteria. It has antibacterial effects against the bacteria involved in breakouts.
Calms inflammation. That's why it helps with rosacea redness and bumps.
Keeps pores clearer by normalizing how skin cells shed inside the follicle.
(Schulte et al., 2015)
What the studies show
Melasma. In a 24-week double-blind trial of 329 women, 20% azelaic acid cream was compared head-to-head with 4% hydroquinone, both used with sunscreen. Azelaic acid gave good or excellent results in 65% of patients, with no significant difference from hydroquinone in overall rating, lesion size, or pigment intensity. No ochronosis or allergic reactions were seen with azelaic acid. (Balina & Graupe, 1991)
Rosacea. Two large phase III trials tested 15% azelaic acid gel twice daily for moderate rosacea. It reduced inflammatory bumps by 58% and 51%, compared with 40% and 39% for the plain gel. It also improved redness in more patients (44–46% vs. 28–29%). (Thiboutot et al., 2003) In another trial against metronidazole, a common rosacea prescription, more azelaic acid patients reached a rating of clear, minimal, or mild (69% vs. 55%), though azelaic acid caused a bit more stinging. (Elewski et al., 2003)
Acne. Azelaic acid 20% cream is FDA-approved for acne, and it's especially useful when breakouts leave behind dark marks, since it treats both at once.
Why it's a favorite during pregnancy
Many of the go-to acne and pigment treatments, like retinoids, are off the table during pregnancy. Azelaic acid is minimally absorbed through the skin, and clinical reviews list it as a recommended baseline option for acne during pregnancy. (Chien et al., 2016) As always, check with your OB or provider before starting anything new while pregnant or breastfeeding.
Prescription vs. over-the-counter
Prescription: 15% gel or foam (rosacea) and 20% cream (acne). These are the strengths studied in the big trials.
Over-the-counter: usually 10% or less. These can be helpful, but they haven't been studied as rigorously.
How to use azelaic acid
Apply a thin layer to clean, dry skin once or twice daily, as directed.
Mild tingling, itching, or stinging in the first few weeks is common and usually fades. If it doesn't, or you get a rash, stop and check in.
Follow with moisturizer, and always use sunscreen in the morning.
Give it time. Most studies measured results at 12 to 24 weeks.
Myth vs. Fact
Myth: Azelaic acid is just for acne. Fact: It has strong research for melasma and rosacea too. That range is what makes it special.
Myth: Gentle means it doesn't really work. Fact: In a large trial, 20% azelaic acid performed on par with 4% hydroquinone for melasma.
What newer research shows
Newer research backs up what the classic trials found:
A 2023 meta-analysis pooled 6 randomized trials with 673 melasma patients. Azelaic acid lowered melasma severity scores slightly more than hydroquinone, with no significant difference in side effects. The gap was small, so the fair takeaway is that the two are comparable. (Albzea et al., 2023)
A recent review of azelaic acid's mechanisms confirms why it works across so many conditions: it calms inflammation, fights acne bacteria, normalizes pore-clogging skin cells, and slows pigment production. (Azelaic acid review)
Larger, longer trials are still needed, especially ones that follow patients after treatment ends.
The honest bottom line
Azelaic acid is one of the most versatile, well-tolerated ingredients we have. It won't work overnight, and over-the-counter strengths are weaker than what was studied, but for melasma, rosacea, acne, and post-acne marks, especially during pregnancy, it deserves a spot in the conversation.
Wondering if azelaic acid belongs in your routine? Book a consultation with Then & Now Aesthetics and Wellness, and let's build a plan that fits your skin and your season of life.
You, Beautifully Enhanced.
This post is for educational purposes and isn't a substitute for personalized medical advice.
About the Author
Rebecca Guiheen, BSN, RN, is the founder of Then & Now Aesthetics and Wellness in Kansas City. She brings 15 years of ICU nursing experience to her aesthetics practice and is completing her Family Nurse Practitioner (FNP) degree, with a focus on hormonal health and aging gracefully.
References
Balina LM, Graupe K. The treatment of melasma: 20% azelaic acid versus 4% hydroquinone cream. Int J Dermatol. 1991;30(12):893–895. https://pubmed.ncbi.nlm.nih.gov/1816137/
Thiboutot D, Thieroff-Ekerdt R, Graupe K. Efficacy and safety of azelaic acid (15%) gel as a new treatment for papulopustular rosacea: results from two vehicle-controlled, randomized phase III studies. J Am Acad Dermatol. 2003;48(6):836–845. https://pubmed.ncbi.nlm.nih.gov/12789172/
Elewski BE, et al. A comparison of 15% azelaic acid gel and 0.75% metronidazole gel in the topical treatment of papulopustular rosacea: results of a randomized trial. Arch Dermatol. 2003;139:1444–1450.
Schulte BC, Wu W, Rosen T. Azelaic acid: evidence-based update on mechanism of action and clinical application. J Drugs Dermatol. 2015;14(9):964–968.
Chien AL, et al. Treatment of acne in pregnancy. J Am Board Fam Med. 2016;29(2):254–262. https://www.jabfm.org/content/29/2/254
Albzea W, et al. Azelaic acid versus hydroquinone for managing patients with melasma: systematic review and meta-analysis of randomized controlled trials. Cureus. 2023;15(7):e41796. https://www.cureus.com/articles/167988
Azelaic acid: mechanisms of action and clinical applications. https://pmc.ncbi.nlm.nih.gov/articles/PMC11512533/
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