From the Guidelines
Azelaic acid and Metrogel (metronidazole) are considered similarly effective first-line topical treatments for papular pustular rosacea, with both reducing inflammatory lesions by 60-70% when used consistently over 8-12 weeks. The choice between the two medications may depend on individual patient factors, such as skin type and potential side effects. Metronidazole is available as a 0.75% or 1% gel, cream, or lotion applied once or twice daily, while azelaic acid comes as a 15% gel or 20% cream applied twice daily 1.
- Key benefits of azelaic acid include its anti-inflammatory, antimicrobial, and mild exfoliating effects, which may be beneficial for patients with sensitive skin or those who have not responded to metronidazole 1.
- Metronidazole, on the other hand, has anti-inflammatory and antimicrobial properties, and has been shown to be effective in reducing inflammatory lesions and perilesional erythema associated with rosacea 1.
- Both medications are generally well-tolerated, although azelaic acid may cause more initial stinging or burning 1.
- If one treatment does not provide adequate improvement after 8-12 weeks, switching to the other is a reasonable approach, or combining either topical treatment with oral antibiotics like doxycycline may be necessary for more severe cases 1.
- A phenotype-led treatment algorithm, as recommended by the global rosacea consensus (ROSco) panel, suggests that azelaic acid and metronidazole are both first-line treatment options for inflammatory papules and pustules, with the choice of treatment depending on the individual patient's symptoms and severity of disease 1.
From the Research
Comparison of Azelaic Acid and Metrogel for Papular Pustular Rosacea
- Azelaic acid and Metrogel (metronidazole) are both used to treat papular pustular rosacea, but their effectiveness can vary.
- A study published in 2007 found that azelaic acid 15% gel is effective and safe for the treatment of inflammatory papulo-pustular rosacea, with high efficacy and mild, transient local irritation 2.
- Another study from 2006 compared the efficacy of once-daily metronidazole 1% gel with twice-daily azelaic acid 15% gel and found similar reductions in inflammatory lesion counts and high success rates in both treatments 3.
Efficacy of Azelaic Acid
- Azelaic acid 15% gel has been shown to be effective in reducing inflammatory lesion counts and erythema severity in patients with papulopustular rosacea, with continuous decreases in lesion counts and erythema throughout the treatment period 4.
- A study published in 2011 found that azelaic acid gel 15% is approved by the US Food and Drug Administration (FDA) for the treatment of papulopustular rosacea and has been demonstrated to be effective and safe as monotherapy 5.
Comparison with Metronidazole
- A randomized trial published in 2003 found that 15% azelaic acid gel was superior to 0.75% metronidazole gel in reducing mean nominal lesion count and mean percent decrease in inflammatory lesions, as well as in improving erythema severity 6.
- Another study from 2004 found that azelaic acid 15% gel was significantly more effective than metronidazole 0.75% gel in reducing inflammatory lesion counts and erythema severity, with azelaic acid gel demonstrating progressive improvement through week 15 4.
Safety and Tolerability
- Both azelaic acid and metronidazole have been shown to be well-tolerated, with mild, transient local irritation being the most common adverse event 2, 4.
- A study published in 2006 found that both metronidazole 1% gel and azelaic acid 15% gel had similar safety profiles, with no serious or systemic treatment-related adverse events reported 3.