Ingredients

Azelaic Acid: The Underrated Multitasker for Acne, Rosacea, and Dark Spots

Azelaic acid treats acne, rosacea, and hyperpigmentation with fewer side effects than retinoids. Learn about concentrations, usage tips, and products.

Azelaic Acid: The Underrated Multitasker for Acne, Rosacea, and Dark Spots

A 2023 systematic review in the Journal of Cosmetic Dermatology found that 20% azelaic acid was 3.06 times more effective than placebo for reducing acne severity after six weeks, while matching hydroquinone's results for melasma without the long-term safety concerns. Despite this evidence, azelaic acid remains one of the most underused ingredients in skincare.

Quick Summary:

  • Azelaic acid treats acne, rosacea, and hyperpigmentation through multiple mechanisms simultaneously
  • Available concentrations range from 10% (over-the-counter) to 20% (prescription)
  • Clinical studies show efficacy comparable to retinoids for acne with superior tolerability
  • For melasma, 20% azelaic acid matches or outperforms hydroquinone without risk of ochronosis
  • Safe during pregnancy, making it one of the few effective actives for expectant mothers

What Is Azelaic Acid?

Azelaic acid is a naturally occurring dicarboxylic acid produced by a yeast called Malassezia furfur that lives on normal skin. In skincare, it's synthesized for consistency and used at concentrations between 10% and 20%.

Unlike most skincare actives that target one concern, azelaic acid works across multiple pathways: it kills acne-causing bacteria, reduces inflammation, normalizes how skin cells shed, and inhibits excess melanin production. This multi-target approach makes it effective for conditions that share underlying mechanisms — particularly acne that leaves dark marks behind.

The FDA has approved 15% azelaic acid gel for treating papulopustular rosacea, and dermatologists widely prescribe it off-label for acne and hyperpigmentation.

How Azelaic Acid Works

Azelaic acid's versatility comes from affecting several cellular processes at once:

Antibacterial action: It disrupts microbial cellular metabolism and membrane pH balance in Cutibacterium acnes (the bacteria behind inflammatory acne). Unlike antibiotics, azelaic acid doesn't promote bacterial resistance, making it suitable for long-term use.

Anti-inflammatory effects: It inhibits NADPH oxidase in neutrophils and suppresses kallikrein 5 (KLK5) and cathelicidin — two key drivers of the inflammation seen in rosacea. This reduces the reactive oxygen species that damage skin and trigger redness.

Melanin regulation: Azelaic acid competitively inhibits tyrosinase by competing with L-tyrosine for the enzyme's active site. It also decreases expression of TRP-1 and TRP-2 proteins involved in melanin synthesis. Critically, it targets only hyperactive melanocytes, leaving normally functioning pigment cells alone.

Keratolytic effects: It normalizes follicular keratinization by inhibiting DNA, RNA, and protein synthesis in abnormally dividing keratinocytes. This prevents the clogged pores that lead to comedonal acne.

Smooth azelaic acid cream texture

Azelaic Acid for Acne

A systematic review analyzing multiple clinical trials found that 64% of patients using 20% azelaic acid achieved "good to excellent" improvement versus 36% with vehicle alone at three months. These results are comparable to topical retinoids and benzoyl peroxide, but with notably fewer side effects.

Where azelaic acid particularly excels is treating acne and its aftermath simultaneously. A 2024 study in Dermatology and Therapy demonstrated that 15% azelaic acid gel significantly reduced both post-inflammatory erythema (the red marks) and post-inflammatory hyperpigmentation (the dark marks) left behind after breakouts clear.

This dual action means you can treat active breakouts and fade acne scars with a single ingredient instead of layering multiple products.

Azelaic Acid for Rosacea

For rosacea, 15% azelaic acid is one of the most evidence-backed topical treatments available. Clinical trials show it significantly improves erythema severity, inflammatory lesion counts, and overall skin appearance compared to vehicle after 12 weeks. Head-to-head comparisons show it outperforms metronidazole 0.75% — one of the most commonly prescribed rosacea treatments — for reducing both redness and inflammatory lesions.

Azelaic acid routine essentials

Azelaic Acid for Hyperpigmentation

A 2023 meta-analysis of six randomized controlled trials compared azelaic acid directly against hydroquinone for melasma. The results: 20% azelaic acid outperformed 2% hydroquinone (73% improvement versus 19% after 24 weeks) and matched 4% hydroquinone without the adverse effects. Since hydroquinone carries a risk of ochronosis (paradoxical darkening) with long-term use, azelaic acid offers a safer alternative for extended treatment.

Verdict: Azelaic acid is one of the most versatile and underappreciated ingredients in skincare. It matches retinoids for acne, beats metronidazole for rosacea, and rivals hydroquinone for hyperpigmentation — all with a gentler side effect profile. If you deal with any combination of these concerns, azelaic acid should be on your radar.

Choosing the Right Concentration

10% (over-the-counter): Available without a prescription in products like The Ordinary Azelaic Acid Suspension 10% (around $8). Effective for mild acne and early hyperpigmentation, and a good starting point for sensitive skin.

15% (prescription): The standard for rosacea treatment. Products like Finacea gel require a prescription but deliver stronger results for inflammatory conditions. Ask your dermatologist if your acne or rosacea isn't responding to 10%.

20% (prescription): Used for more resistant hyperpigmentation and melasma. Available as a cream formulation by prescription. This concentration shows the strongest results in clinical trials but may cause more initial irritation.

How to Use Azelaic Acid

Start slowly: Apply a thin layer once daily in the evening for the first two weeks, then increase to twice daily if tolerated. Some tingling or mild stinging is normal when you begin — it typically resolves within two to four weeks.

Application order: After cleansing and any water-based serums, apply azelaic acid before moisturizer. Its slightly acidic pH works best on relatively clean skin without heavy layers underneath.

Pair it wisely: Azelaic acid combines well with niacinamide (both reduce inflammation and pigmentation) and with moisturizers containing ceramides. A niacinamide serum like The Ordinary Niacinamide 10% + Zinc 1% (around $7) makes an excellent companion product. Avoid layering it with other strong acids like glycolic acid in the same routine to prevent irritation.

Sun protection: While azelaic acid doesn't increase photosensitivity like retinoids do, any depigmenting treatment works better when you protect against new UV-induced melanin. Use a broad-spectrum SPF 30+ sunscreen daily — EltaMD UV Clear SPF 46 (around $40) is a dermatologist favorite that won't aggravate acne or rosacea. See our sunscreen guide for more recommendations.

Who Should Use Azelaic Acid

Azelaic acid is an excellent choice for:

  • Acne with dark marks — treats breakouts and fades post-inflammatory hyperpigmentation simultaneously
  • Rosacea — FDA-approved and proven more effective than metronidazole
  • Sensitive skin — better tolerated than retinoids, AHAs, and benzoyl peroxide
  • Pregnancy — classified as Category B, one of the few effective actives considered safe during pregnancy
  • Melanin-rich skin tones — targets only hyperactive melanocytes, making it safer for dark skin than hydroquinone

Those with very dry skin should pair azelaic acid with a rich moisturizer like CeraVe Moisturizing Cream (around $16), as the ingredient can be mildly drying.

Common Mistakes with Azelaic Acid

Giving up too early. Azelaic acid takes 4-8 weeks to show visible results for acne and 8-12 weeks for hyperpigmentation. Stopping at two weeks because "nothing is happening" means missing the benefits entirely.

Using too much product. A pea-sized amount covers the full face. Applying more doesn't speed results but does increase irritation.

Skipping it because it tingles. Mild stinging in the first few weeks is expected and not a sign of damage. If stinging persists beyond a month or is accompanied by redness and peeling, reduce frequency or try a lower concentration.

Frequently Asked Questions

Can I use azelaic acid every day?

Yes. Most people tolerate twice-daily application after an initial adjustment period of one to two weeks. Start with once daily and increase as your skin adapts.

Does azelaic acid cause purging?

Mild purging is possible during the first two to four weeks as azelaic acid normalizes cell turnover and pushes existing clogs to the surface. This differs from a breakout reaction because purging occurs in areas where you typically get acne and resolves within a month.

Can I use azelaic acid with retinol?

Yes, but introduce them at different times of day — azelaic acid in the morning, retinol at night — or alternate nights. Using both in the same routine can increase irritation. See our guide to layering active ingredients for more combinations.

Is azelaic acid safe during pregnancy?

Azelaic acid is FDA Category B, meaning animal studies show no harm and it's one of the few acne and pigmentation treatments dermatologists recommend during pregnancy. Always confirm with your OB-GYN.

How long until I see results?

Acne improvement typically appears within four to eight weeks. Rosacea redness decreases noticeably by 8-12 weeks. Hyperpigmentation fading requires the longest commitment — often 12-24 weeks of consistent use.

Is 10% azelaic acid effective, or do I need prescription strength?

The 10% concentration available over the counter is effective for mild to moderate concerns. If you have persistent rosacea, stubborn acne, or significant hyperpigmentation, prescription 15% or 20% formulations deliver stronger results backed by the majority of clinical trials.

Can azelaic acid replace my BHA?

For acne treatment, azelaic acid and salicylic acid work through different mechanisms. Salicylic acid is better at dissolving oil within pores, while azelaic acid is stronger at killing bacteria and reducing pigmentation. You can alternate them or use one in the morning and one at night.

Does azelaic acid lighten normal skin?

No. Azelaic acid specifically targets hyperactive melanocytes — cells producing excess melanin. It doesn't affect normally functioning pigment cells, so it won't lighten your natural skin tone.

What's the difference between azelaic acid and glycolic acid?

Glycolic acid is an AHA that works primarily through exfoliation — dissolving the bonds between dead skin cells. Azelaic acid works through antibacterial, anti-inflammatory, and melanin-inhibiting pathways. Glycolic acid is better for texture and dullness; azelaic acid is better for acne, rosacea, and pigmentation.

Can I use azelaic acid on my body?

Yes. Azelaic acid works on body acne and hyperpigmentation, though you'll need more product to cover larger areas. The 10% concentration is practical for body use since prescription strengths become expensive over large surface areas.

Why isn't azelaic acid more popular?

Lack of marketing. Azelaic acid is a generic ingredient without a major brand champion, so it doesn't receive the advertising dollars that retinol, vitamin C, or hyaluronic acid enjoy. Its clinical evidence is strong — it simply hasn't had the marketing push.

The Bottom Line

Azelaic acid is a clinically proven ingredient that treats acne, rosacea, and hyperpigmentation through multiple mechanisms with fewer side effects than most alternatives. Start with a 10% over-the-counter product, use it consistently for at least eight weeks, and consider stepping up to prescription strength for stubborn concerns.

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