What is the role of azelaic acid in treating acne and what are its benefits?

Role of Azelaic Acid in Acne Treatment and Its Benefits

Azelaic acid is an effective topical treatment for mild to moderate inflammatory acne vulgaris, offering multiple beneficial mechanisms including antimicrobial, anti-inflammatory, and comedolytic properties with a favorable safety profile. 1

Mechanism of Action

• Azelaic acid works through multiple mechanisms to combat acne:
  • Antimicrobial activity against Propionibacterium acnes and Staphylococcus epidermidis 2
  • Normalization of keratinization leading to an anticomedonal effect 2
  • Reduction in stratum corneum thickness and changes in keratohyalin granules, suggesting ability to decrease microcomedo formation 2
  • Anti-inflammatory properties that help reduce inflammatory acne lesions 1

Clinical Efficacy

• In clinical trials, azelaic acid 20% cream demonstrated significant efficacy:
  • 28% more patients achieved 50-100% reduction in total lesion count compared to vehicle at 3 months 1
  • Total lesion count reduction of 60.6% compared to 19.9% with placebo in controlled studies 3
  • Acne severity index (ASI) reduction of 65.2% versus 21.3% with placebo, making azelaic acid 3.06 times more effective 3
  • Comparable efficacy to other topical acne treatments including tretinoin, benzoyl peroxide, erythromycin, and oral tetracycline 4

Dosing and Administration

• Recommended application:
  • A thin film should be gently but thoroughly massaged into affected areas twice daily, in the morning and evening 1
  • Available as a 20% cream formulation for acne treatment 1

Safety Profile and Tolerability

• Common side effects include:

  • Pruritus, burning, stinging, tingling, erythema, dryness, rash, peeling, irritation, dermatitis, and contact dermatitis 1
  • These side effects are generally mild and transient 4, 5

• Pregnancy considerations:

  • Pregnancy category B, indicating minimal risk 1
  • Risk of fetal harm is not expected based on limited systemic absorption 1
  • Only about 4% of topically applied azelaic acid is systemically absorbed 2

• Nursing considerations:

  • Minimally distributed into breast milk after topical application 1
  • Caution advised if used in nursing women 1

Special Populations and Considerations

• Pediatric use:

  • Safety and effectiveness have not been established in patients under 12 years of age 1

• Skin type considerations:

  • Particularly beneficial for patients with sensitive skin or darker skin types (Fitzpatrick IV or greater) due to its lightening effect on post-inflammatory hyperpigmentation 1
  • Suitable for use on all skin types 5

Additional Benefits

• Beyond acne treatment, azelaic acid has shown efficacy in:
  • Treatment of hyperpigmentary disorders including melasma 4
  • Management of rosacea (15% gel formulation) 5
  • Potential benefit for post-inflammatory hyperpigmentation that often accompanies acne 1

Place in Acne Treatment Algorithm

• The American Academy of Dermatology conditionally recommends azelaic acid for acne treatment based on moderate certainty evidence 1
• Most appropriate for:
  • Mild to moderate inflammatory acne vulgaris 1
  • Patients with sensitive skin who cannot tolerate other topical treatments 1
  • Patients with darker skin types concerned about post-inflammatory hyperpigmentation 1
  • Pregnant patients requiring acne treatment (Category B) 1

Combination Therapy Considerations

• May be used as part of a multimodal therapy approach:
  • Can be combined with topical retinoids if comedonal components are present 1
  • Effective as both monotherapy or in combination with other acne treatments 4