What is Finacea (Azelaic Acid)?
Finacea is the brand name for azelaic acid 15% gel, a topical medication FDA-approved for treating rosacea and acne, but it is also an effective treatment option for melasma, particularly as an alternative to hydroquinone.
Mechanism and Formulations
- Azelaic acid is available in 20% cream formulation (as well as 15% gel under the brand name Finacea) and works as a tyrosinase inhibitor to reduce melanin production in hyperpigmented skin 1
- The medication has demonstrated efficacy in treating melasma through its depigmenting properties 1
Evidence for Melasma Treatment
Comparative Efficacy
- In a head-to-head comparison, 20% azelaic acid cream demonstrated superior efficacy to hydroquinone 4% cream after 2 months of twice-daily application 1
- After 2 months of treatment, the mean MASI score decreased to 3.8 ± 2.8 with azelaic acid compared to 6.2 ± 3.6 with hydroquinone, showing statistically significant superiority 1
- Both treatments showed similar results at 1 month, but azelaic acid's advantage became apparent with continued use 1
Role in Combination Therapy
- Azelaic acid 20% has been studied as part of novel combination formulations with tazarotene 0.075%, tacrolimus 0.1%, and zinc oxide 10% for moderate-to-severe melasma 2
- This combination approach showed significant MASI score reduction from baseline (median 18.9 points) to Week 20 (median 13.3 points, p=0.001) 2
- Treatment-related adverse events were mild and typically decreased over the course of therapy 2
Position in Treatment Algorithm
- While the American Academy of Dermatology recommends triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) as first-line therapy combined with strict sun protection (SPF 50+ reapplied every 2-3 hours), azelaic acid serves as an effective alternative 3
- Azelaic acid is particularly valuable for patients who cannot tolerate hydroquinone or wish to avoid it due to concerns about long-term use 4
Application Protocol
- Apply azelaic acid cream twice daily to affected areas 1
- Must be combined with broad-spectrum sunscreen (minimum SPF 30, preferably SPF 50+) reapplied every 2-3 hours during outdoor exposure 3
- Additional photoprotection measures include wearing wide-brimmed hats (>3-inch brim), seeking shade during peak UV hours (10 a.m. to 4 p.m.), and using UV-protective clothing 3
Safety Profile
- Azelaic acid has a favorable safety profile with mild adverse events primarily consisting of skin irritation, dryness, burning, and erythema 4
- These side effects are generally well-tolerated and often diminish with continued use 2
Important Clinical Considerations
- Melasma is a chronic condition requiring long-term maintenance therapy—discontinuing treatment too early leads to high recurrence rates 3
- Patients should be counseled to avoid smoking, which can worsen melasma 3
- Hormonal influences (pregnancy, oral contraceptives, hormone replacement therapy) may limit treatment success and should be addressed 3
- Treatment efficacy should be measured using standardized mMASI scores, with decreases >60-90% indicating moderate improvement and >90% indicating excellent response 3