What is the recommended treatment and dosage for acne using azelaic acid?

Azelaic Acid for Acne Treatment

For acne treatment, azelaic acid should be applied as a 20% cream formulation, with a thin film gently but thoroughly massaged into affected areas twice daily (morning and evening) after washing and drying the skin. 1, 2

Efficacy and Mechanism

• 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 1
• It provides mild comedolytic effects along with anti-inflammatory and antibacterial properties, making it particularly effective for inflammatory acne lesions 1, 3
• Clinical improvement typically occurs within four weeks for most patients with inflammatory lesions 2
• In clinical trials, azelaic acid 20% cream demonstrated significant efficacy, with 28% more patients achieving 50-100% reduction in total lesion count compared to vehicle at 3 months 1

Dosage and Administration

• Apply a thin film of azelaic acid 20% cream twice daily (morning and evening) to affected areas after thoroughly washing and patting the skin dry 1, 2
• Hands should be washed following application 2
• Treatment duration varies depending on acne severity, but improvement typically occurs within four weeks for inflammatory lesions 2
• Continuous use is necessary to maintain clinical response 1

Special Populations and Considerations

• Azelaic acid is particularly beneficial for patients with:
  • Sensitive skin 1, 3
  • Darker skin types (Fitzpatrick IV or greater) due to its lightening effect on post-inflammatory hyperpigmentation 1, 3
  • Pregnant patients requiring acne treatment (Pregnancy category B) 1, 3

Side Effects 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 1
• If excessive irritation occurs, consider reducing application frequency temporarily 3

Position in Treatment Algorithm

• Azelaic acid is considered a second-line option for purely comedonal acne, with topical retinoids and salicylic acid being first-line options 3, 4
• For mild to moderate inflammatory acne, azelaic acid can be used as an effective first-line treatment 1
• In comparative studies, 15% azelaic acid gel demonstrated comparable efficacy to 5% benzoyl peroxide and 1% clindamycin, with a 70% median reduction in inflammatory lesions 5

Clinical Pearls

• Azelaic acid has a favorable safety profile compared to some alternatives, with less irritation than benzoyl peroxide but more than clindamycin 5
• The 20% cream formulation is specifically indicated for acne treatment, while a 15% gel formulation is also available (primarily for rosacea) 1, 6
• Azelaic acid can be particularly useful in adult female acne, which often presents with inflammatory lesions and may be persistent or late-onset 7
• Consider azelaic acid as part of combination therapy for more severe or resistant cases, as combination approaches are often more effective than monotherapy 3