It makes sense to assume that strong treatments are necessary for clearing up stubborn acne and rosacea, but they can actually make those inflammatory conditions worse. That’s where azelaic acid comes in. Many common treatments for pimples and redness, instead of calming your skin, might be too harsh and make it flaky and/or even more inflamed. But lesser-known azelaic acid is an acne fighter that’s much gentler than many other active ingredients. In fact, it’s not only safe to use with a variety of additional products and actives, but it’s even considered generally safe to use during pregnancy, which you can’t say about some other acne-treating ingredients like retinol (keep scrolling for more details on that).
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Curious about making the switch from harsher products to something that might be much kinder to your face? Here's what you need to know about treating acne or redness with azelaic acid—in both its prescription and over-the-counter formulas.
What is azelaic acid? | What are the prescription options for azelaic acid? | What about over-the-counter azelaic acid products? | Is azelaic acid safe for pregnant people? | How long does it take for azelaic acid to work? | How do you get started with azelaic acid?
What is azelaic acid and what does it do for your skin?
"Azelaic acid is a dicarboxylic acid that's synthesized by yeast naturally; now it’s made from products like barley and wheat," Temitayo A Ogunleye, MD, assistant professor of clinical dermatology at the University of Pennsylvania Perelman School of Medicine, tells SELF.
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The relationship between azelaic acid and acne works like this: Azelaic acid has antibacterial properties that contribute both to its acne-fighting capabilities and its effectiveness at calming the skin and preventing inflammation. This anti-inflammatory benefit is also what makes azelaic acid useful for people with rosacea, Dr. Ogunleye says. Basically, bacteria is the enemy when it comes to acne, and even rosacea in some cases. “Overgrowth of bacteria or yeast in the pores contributes to acne. Azelaic acid reduces these organisms on the skin, and calms inflammation, redness, and swelling,” Azadeh Shirazi, MD, board-certified dermatologist and owner of La Jolla Laser Derm in La Jolla, California, tells SELF. (The bacteria that causes acne also triggers the production of inflammatory cytokines, Dr. Ogunyele adds, which are part of your immune system's response to pathogens.)¹
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In addition to reducing acne-causing bacteria, azelaic acid has gentle exfoliating properties that can help remove dead skin cells on the very outer layer of the skin, the stratum corneum, leading to a smoother and brighter complexion, says Dr. Shirazi. Plus, regular exfoliation–which can unclog your pores—may make breakouts less likely. Glycolic acid and salicylic acid are other exfoliants commonly recommended for acne-prone skin, but they’re harsher and more likely to lead to irritation and flakes than azelaic acid, adds Dr. Shirazi.
Research also suggests that azelaic acid is a skin brightener that can help with managing hyperpigmentation (such as melasma and post-acne dark spots) in all skin tones by indirectly destroying melanocytes, which are the skin cells that produce melanin.² “It inhibits tyrosinase, the enzyme involved in the production of pigment,” Dr. Shirazi says. Many dermatologists might suggest vitamin C for reducing pigment in the skin, but azelaic acid can be a gentler replacement for fading dark spots. “Many people are sensitive to vitamin C or it causes them to break out, so azelaic acid is a great alternative,” Dr. Shirazi says.
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Since it can be so effective in fading hyperpigmentation and calming inflammation, you might also consider using azelaic acid to treat and prevent acne scarring. “Because of its anti-inflammatory, mild antimicrobial, and tyrosinase-inhibiting properties, it can help with acne and rosacea as well as help fade the hyperpigmentation associated with acne blemishes,” Susan Massick, MD, board-certified dermatologist at The Ohio State University Wexner Medical Center, tells SELF.
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What are the prescription options for azelaic acid?
Azelaic acid can be prescribed in two concentrations: azelaic acid 15% (Finacea) and azelaic acid 20% (Azelex). Both come in an azelaic acid gel or azelaic acid foam consistency.
And we have a pretty good idea that both are effective: A systematic review of the clinical trials of both concentrations published in 2006 in JAMA Dermatology included data for five studies (873 participants). The researchers concluded that both azelaic acid 15% and azelaic acid 20% formulations were effective at treating rosacea, especially the papules and pustules associated with the condition.³ (The other common symptoms—persistent flushing and visible blood vessels—are notoriously difficult to manage without laser treatments, John G. Zampella, MD, assistant professor in the Ronald O. Perelman department of dermatology at NYU Langone Health, tells SELF.
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The azelaic acid 20% formulation has already been greenlit for the treatment of acne, but a 2018 study in the Journal of Drugs in Dermatology suggests that the azelaic acid 15% formulation is also effective and safe in treating moderate to severe acne. (The study’s 20 participants had a few side effects like mild dryness and peeling that resolved by the end of the study.)⁴
But these azelaic acid prescription options are not always accessible. "The problem with those is that it's getting harder and harder to get them covered by insurance," Dr. Zampella says. And without insurance, "azelaic acid prescriptions can be very expensive," Dr. Ogunleye says—usually a few hundred dollars. That's why, if your insurance doesn't cover it, your dermatologist may direct you to an over-the-counter product containing azelaic acid. Which brings us to our next point…
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What about nonprescription azelaic acid products?
There are a few options available, but note that there's not enough evidence to suggest that they significantly improve rosacea or acne. For instance, The Ordinary makes a 10% azelaic acid suspension (available for $10) that’s much cheaper than an azelaic acid prescription. If a patient's prescription isn't covered by insurance, Dr. Ogunleye says she'll often suggest her patients look for over-the-counter versions online. There you can also find Paula's Choice Boost 10% Azelaic Acid Booster ($36), which also contains salicylic acid (but if you have sensitive skin that’s prone to flaking with acne treatment products, this might not be your best bet).
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There's not much research on these concentrations (and none on the specific products above), but there is one study, published in 2014 in the Journal of Medical Sciences, that showed promise for a lower-than-prescription concentration. Researchers looked at 40 participants with mild to moderate acne, all of whom received a 10% azelaic acid gel (half got it in an alcohol-free base while the other half got it in a base that contained alcohol). After eight weeks, the severity of both groups' acne went down significantly, but there were no differences between groups, suggesting that a 10% concentration of azelaic acid could help with acne.⁵
But there are also some obvious drawbacks to this study, including the fact that it had a relatively small sample size, there was no control group, and there was no comparison against an azelaic acid 15% or 20% concentration.
So, these options may not be as effective as the prescription versions, but they may still be "worth a try," Dr. Ogunleye says. And Dr. Massick agrees that while they’re less potent than azelaic acid 15% or azelaic acid 20% concentrations, 10% is a good place to start and a reasonable price point for azelaic acid. "My general approach if we can’t get the prescription strength covered is that I’ll have a patient try the 10%," Dr. Zampella adds. "Azelaic acid is one of the safest of the medicines you could try," he says—so the potential benefits usually outweigh the risks.
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Is azelaic acid safe for pregnant people?
Unlike some acne treatments (including retinoids and benzoyl peroxide), azelaic acid is generally considered safe to use during pregnancy. According to the American Academy of Dermatology, there isn't research in pregnant humans, but data from animal studies suggests that it doesn't cause any birth defects when applied to the skin. “There’s minimal fetal exposure when azelaic acid is used topically,” Dr. Massick says. “Less than 4% is absorbed by the skin when applied topically, plus it’s usually applied in small, specific areas.” That said, because the research is limited, it’s smart to ask your doctor if azelaic acid is right for you.
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How long does it take for azelaic acid to work?
In general, if you're using azelaic acid to address acne or rosacea, Dr. Zampella suggests sticking with it for three months before deciding whether or not it works for you. But some people may see a benefit within four to six weeks or even sooner. If you're using it to address pigmentation concerns, "some people start seeing a benefit within a week," he says.
You can use azelaic acid long-term as an everyday product (Dr. Shirazi recommends applying azelaic acid after cleansing in the morning and at night). “I suggest long-term use for my rosacea patients or those with melasma or chronic acne and sensitive skin for maintenance therapy,” Dr. Shirazi says. Though it’s safe and effective for long-term acne treatment, it may not be the best go-to product for the occasional breakout. It’s not as powerful an ingredient as retinol for treating acne, but it’s more gentle for sensitive skin, she adds.
If you skip a morning or evening dose of azelaic acid, nothing bad will happen, but it’s best to keep it as consistent as possible and apply the dose as soon as you remember. “You may find it’s not as effective if you forget to use it consistently,” says Dr. Massick.
It's a good idea to stay away from harsh or potentially irritating products (like those outlined above) while your skin adjusts to azelaic acid, and it's always a good idea to limit the amount of exfoliating products you're using at one time to limit irritation . You technically can use azelaic acid with a physical exfoliant like a facial scrub, but you wouldn’t want to use the azelaic acid, a scrub, and a powerful chemical exfoliant like glycolic or salicylic acid all together, says Dr. Shirazi. Using all of those options could result in over-exfoliation, peeling away too many layers of skin and irritating your skin barrier.
But, overall, azelaic acid is a pretty easygoing ingredient, Dr. Zampella says. And there isn't really anything you can never use it with, Dr. Ogunleye adds, although it's always smart to ask your derm about potential problems with ingredient combinations. Really, "the biggest barrier is getting it covered by insurance," Dr. Zampella says.
If you have any questions about using azelaic acid or if you want to find out whether you qualify for an azelaic acid prescription, talk to your dermatologist. Of course, there are also the 10% over-the-counter options, which, per the doctors we talked to, is a fine—and way cheaper—place to start.
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How do you get started with azelaic acid?
Acids, especially those used to treat acne, tend to be harsh, but most people—even those with sensitive skin or rosacea—are able to use azelaic acid with minimal problems, Dr. Zampella says. Like any acid, it can be irritating, he adds, but this irritation usually goes away over time.“Azelaic acid tends to be less irritating than either benzoyl peroxide or a retinoid,” Dr. Massick adds. “It won’t bleach clothing the way that benzoyl peroxide can either, and it doesn’t cause peeling, dryness, or irritation in the way that a retinoid can.”
Dr. Zampella suggests starting off slowly when applying azelaic acid for the first time—to prevent any mild irritation—by putting a small amount on the inside of your arm for a patch test. If that goes okay and doesn’t irritate your skin after 24 hours or so, you can put a thin layer on your face up to twice a day, or according to your prescription instructions. If you know you have sensitive skin, though, it's best to start out using it once every other day to see how you handle it, Dr. Ogunleye adds.
If you feel itchiness, burning, or stinging that doesn't go away, that's a sign to back off and check in with your derm. Other symptoms such as swelling, a rash, or difficulty swallowing or breathing constitute an emergency and could signal an allergy.
The experts we talked to recommend using azelaic acid in place of another acne-fighting ingredient like retinol or salicylic acid (too many acne treatments at once can be harsh on your skin, which is what you’re probably trying to avoid by using azelaic acid). However, you can combine it with other gentler skin-care active ingredients like niacinamide—a form of vitamin B3 that can also potentially treat acne and rosacea—or in conjunction with ceramides, adds Dr. Shirazi.
Oh, another thing to note: Once you start using azelaic acid, it’s important to store it properly—at room temperature, like you would with most other skin-care products “It’s best to avoid extreme temperatures that could decrease the medication’s effectiveness, so don’t put it in the fridge or freeze it,” Dr. Massick says. “And definitely keep it away from heat, particularly azelaic acid foam, because it’s more flammable than other formulas.” Azelaic acid has no chill.
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- Journal of Immunology, Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses
- Indian Journal of Dermatology, Topical Treatment of Melasma
- JAMA Dermatology, Azelaic Acid in the Treatment of Papulopustular Rosacea
- Journal of Drugs in Dermatology, The Efficacy and Safety of Azelaic Acid 15% Foam in the Treatment of Facial Acne Vulgaris
- Journal of Medical Sciences, Efficacy of 10% Azelaic Acid Gel with Hydro-alcoholic or Alcohol-free Bases in Mild to Moderate Acne Vulgaris; the First Clinical Trial
- 16 Skin-Care Products Women With Rosacea Love
- 8 Causes of Adult Acne and How to Actually Treat It
- Is Popping Your Pimples Really That Bad?