Azelaic acid

Azelaic acid is a dicarboxylic acid found naturally in grains such as barley, wheat and rye, used on the skin to treat acne, rosacea and pigmentation. Few actives treat all three at once. Fewer still do it gently enough for reactive skin. It is also one of the only ones considered safe in pregnancy. In the UK you can buy azelaic acid over the counter up to 10%. Higher strengths and compounded formulas are prescription only. Your doctor may include azelaic acid in a custom cream or gel designed around your skin at a strength and alongside actives that suit you.

What Is Azelaic Acid and How Does It Work?

Azelaic acid does four things at once. It kills the bacteria involved in acne. Inside the pore, it slows follicular keratinisation, the build-up of dead cells that plugs the follicle, so fewer pores clog and fewer clogged pores become spots. Its anti-inflammatory action is the part that matters in rosacea, where the redness and the bumps come from an immune response rather than a blockage. Gentle exfoliation lifts dullness and softens rough texture. For pigment, azelaic acid competes with tyrosine for the binding site on tyrosinase, the enzyme that makes melanin. So, the skin produces less of it and existing marks fade. This may provide the following benefits:

• Tolerability: gentle enough for sensitive skin, and one of the few actives considered safe in pregnancy.
• Clearer skin: fewer blocked pores, fewer breakouts and less of the congestion that drives them.
• Calmer redness: an anti-inflammatory action suited to rosacea and reactive skin.
• Fading of dark marks: works on the pigment left behind by acne, melasma and sun damage.
• Smoother texture: mild exfoliation that improves roughness and dullness.

How City Skin Clinic Uses Azelaic Acid

Due to its versatility, your doctor may include Azelaic acid in any of our skin treatments. It is a multi-tasking ingredient that works across every concern we treat:

• Acne
• Rosacea
• Hyperpigmentation
• Melasma
• Skin Ageing

Despite its benefits, Azelaic acid is rarely the only active in a custom formula. Pairing it with other actives often helps enhance results, especially if you have more than one skin concern. Your doctor may combine Azelaic acid with one or more of the following:

• Tretinoin: speeds up cell turnover, smooths texture, treats acne and fades pigment faster. Used in acne, melasma, hyperpigmentation and skin ageing formulas. In lower strengths and gentler formulas it can also be used in rosacea.
• Hydroquinone: the strongest pigment suppressor we use to treat hyperpigmentation, melasma and age spots. Azelaic acid can complement its actions and maintain results after stopping Hydroquinone.
• Tranexamic Acid: quietens the signals that switch pigment cells on and is useful in melasma treatment.
• Niacinamide: supports the barrier, minimises pores and helps fade hyperpigmentation.
• Spironolactone: blocks the androgens driving oil production in hormonal acne.
• Clindamycin: an antibiotic for inflammatory acne that can amplify Azelaic acid’s anti-inflammatory actions.
• Metronidazole: a long-standing rosacea treatment that reduces inflammation and can work well alongside Azelaic acid.
• Ivermectin: kills the Demodex mites that may drive some rosacea flares.
• Hydrocortisone: a mild steroid added to some hyperpigmentation and melasma formulas to reduce inflammation, which drives pigment production.

How Do You Get Azelaic Acid in the UK?

There are three routes, and which one you need depends on the strength and on what you are treating. Up to 10%, Azelaic acid is available over the counter. You can buy it as a serum, gel or cream without seeing anyone, and for mild congestion or uneven tone that is often enough. The other two routes are available by prescription only.

Strengths above 10% and compounded formulas are available by prescription only. Two licensed products carry it in the UK, both from Leo Laboratories. Finacea 15% gel is licensed for the papules and pustules of rosacea, and Skinoren 20% cream is licensed for acne. Neither is licensed for hyperpigmentation and each comes in one strength and one base. Compounded formulas are unlicensed prescription treatments made individually for each patient by a specialist pharmacy. Your doctor can select the strength, combine it with other actives and formulate it in a gel or cream. This allows customisation of a treatment that can cover more than one concern.

To access our custom skin treatments, you will need to complete the online consultation form or book a virtual video consultation with one of our doctors first. Your doctor will assess your skin, design a formula around what it needs and look after you afterwards. The same doctor stays with you, adjusts the treatment course by course and answers your questions by email.

There is no subscription and no auto-renewal. Each course is a single order you place yourself.

Over the Counter, Prescription or Compounded Azelaic Acid

If you are considering Azelaic acid, you have three possible routes. You can buy a product up to 10% over the counter, be prescribed one of the two licensed products or have a formula compounded and made for you. Which route suits you depends on your skin, health and what you are treating. This is how the three compare:

How Effective Is Azelaic Acid?

Azelaic acid is licensed in the UK to treat acne and rosacea. It is also sometimes used for hyperpigmentation, melasma and skin ageing based on evidence from clinical studies and reports. This is what the evidence shows for each concern:

• Acne: a Cochrane review of 49 trials found Azelaic acid works about as well as Tretinoin and slightly less well than benzoyl peroxide for some cases of acne.
• Rosacea: Azelaic acid reduces the papules, pustules and redness of rosacea, and in head-to-head trials it performs comparably to topical Metronidazole. It can be used on its own or alongside other rosacea treatments such as Metronidazole and Ivermectin. It also helps maintain results, with one study finding it kept 75% of patients in remission after their rosacea flare had cleared.
• Hyperpigmentation and melasma: in a 24-week trial of 329 women, 20% Azelaic acid produced good or excellent results in 65% of patients, matching 4% Hydroquinone without any cases of ochronosis. Adding Tretinoin also speeds up this fading.
• Skin ageing: the evidence here is more limited than for the other three. Azelaic acid can help even tone and improve texture whilst Tretinoin does more for lines and firmness.

How quickly it works depends on the concern, whether you’re using other actives and how your skin responds. For mild concerns, some people may see a first visible change as early as four weeks with the full effect over several months. Breakouts and redness usually settle before hyperpigmentation. Melasma is always the slowest condition to shift.

What Strengths Does Azelaic Acid Come In?

Over the counter you will find Azelaic acid up to 10%, most often in a cream, lotion or gel. The licensed prescription products run higher, at 15% in a gel and 20% in a cream.

In our compounded formulas we use anywhere from 5% to 20%. The strength depends on three things. What else is in the formula, the condition being treated and how sensitive your skin is. A formula built around Azelaic acid alone can sit at the top of that range. One that also carries Tretinoin usually sits lower, because the two together at full strength are more than most skin will tolerate. Reactive and rosacea-prone skin often does better starting low and building up. A higher strength is not automatically better, and your doctor will aim for the one you can use consistently without irritation.

What Are the Side Effects of Azelaic Acid?

Most people tolerate Azelaic acid well. The common effects are local and usually settle as your skin adjusts.

• Burning, stinging or tingling on application, most often during the first few weeks.
• Itching, redness, dryness or flaking where you apply it, and is usually mild.
• Purging in cases of acne there may be an initial increase in lesions before settling down.

The licensed products list these among their most common side effects. They tend to ease within the first month. If they do not, the answer is usually to reduce the frequency or lower the strength rather than to stop altogether. Less common effects to tell your doctor about:

• Worsening of asthma: reported rarely with Azelaic acid during post-marketing surveillance.
• Changes in skin colour where you apply it: there have been isolated reports of skin lightening. Azelaic acid has not been well studied in darker skin. If you have a deeper skin tone, your doctor will want to know early if you notice patches of skin over-lightening.
• Allergic reactions: rare, but stop and seek advice if you get swelling of the face or eyes, a rash beyond the application site or any difficulty breathing.

If you are using a formula from us, contact your doctor if you experience any problems. Follow-up is free and most problems can usually be settled by adjusting the protocol instructions.

Who Should Not Use Azelaic Acid?

Azelaic acid tends to be well tolerated by most people, including those with sensitive skin. There are, however, a few situations that need extra care or to avoid it completely:

• Allergy to Azelaic acid or any ingredient in the formula: the only outright contraindication on the licensed labels.
• Asthma: worsening of asthma has been reported rarely with Azelaic acid. Tell your doctor if you have asthma, and if it gets worse whilst you are using it, stop and speak to them.
• Deeper skin tones with a history of patchy lightening: not a reason to avoid it, but a reason for your doctor to monitor and for you to flag any lightening early.
• Broken or inflamed skin: wait until it has settled, and keep it away from the eyes, lips and nostrils.

Azelaic acid is generally considered safe during pregnancy and breastfeeding. With cautious use, it is one of the few options available for acne, rosacea or hyperpigmentation at that time. This is important as actives like Tretinoin, Hydroquinone and certain antibiotics are usually unsuitable during pregnancy or breastfeeding. Your doctor will assess your skin, health and design the best treatment for you. Regardless of safety, infants should not come into contact with the treatment.