It makes sense to assume that strong treatments are necessary for clearing up stubborn acne and rosacea, but they can actually make those inflammatory conditions worse. Azelaic acid is the answer. Instead of soothing your skin, many common remedies for redness and pimples can make it more flaky or inflamed. Azelaic acid, a lesser-known active ingredient in acne treatment, is much gentler than most. In fact, it’s not only safe to use with a variety of additional products and actives, but it’s even considered generally safe to use during pregnancy, which you can’t say about some other acne-treating ingredients like retinol (keep scrolling for more details on that).

Are you interested in switching from harsher products to something more gentle for your skin? This is what you need to know about treating redness or acne with azelaic acids, both prescription and over-the-counter.

What is azelaic acid and how does it affect your skin?

“Azelaic Acid is a dicarboxylic acid, which is naturally synthesized by yeast. Now it’s made from products like barley and wheat,”  says Temitayo A Ogunleye, MD, assistant professor of clinical dermatology at the University of Pennsylvania Perelman School of Medicine.

Azelaic Acid and acne are linked in this way: Azelaic acids have antibacterial properties which contribute to both its acne-fighting abilities and its effectiveness at calming skin and preventing inflammation. Dr. Ogunleye states that azelaic acids is useful for people suffering from rosacea because of its anti-inflammatory properties. “In short, bacteria is the friend of acne and rosacea. Acne is caused by the overgrowth of yeast or bacteria in the pores. Azelaic acid reduces these organisms on the skin, and calms inflammation, redness, and swelling,” says Azadeh Shirazi, MD, board-certified dermatologist and owner of La Jolla Laser Derm in La Jolla, California. Dr. Ogunyele says that acne bacteria trigger the production of inflammatory cytokines. These cytokines are part of your immune response to pathogens.

Dr. Shirazi states that azelaic acids can reduce acne-causing bacteria and has gentle exfoliating qualities. It can remove dead skin cells from the outer layer of your skin, the stratum corneum. This will result in a smoother, brighter complexion. Regular exfoliation, which can unclog pores, may make breakouts less likely. Dr. Shirazi says that while salicylic acid and glycolic acid are also commonly recommended for acne-prone skin types, they can cause irritation and flakes more often than azelaic acids.

Azelaic acid has been shown to be a skin brightener. It inhibits tyrosinase which is an enzyme that produces pigment. Dr. Shirazi agrees. While dermatologists may recommend vitamin C for reducing skin pigment, azelaic acids can be a gentler alternative to fading dark spots. Dr. Shirazi explains that vitamin C can cause skin reactions or even make people break out. Azelaic acid is a great substitute.

Azelaic acid can be very effective in calming inflammation and fading hyperpigmentation. “Because of its anti-inflammatory, mild antimicrobial, and tyrosinase-inhibiting properties, it can help with acne and rosacea as well as help fade the hyperpigmentation associated with acne blemishes,” says Susan Massick, MD, board-certified dermatologist at The Ohio State University Wexner Medical Center.

What prescription options are available for azelaic acids?

Azelaic acids can be prescribed in two concentrations. Finacea has azelaic Acid 15%, and Azelex has azelaic Acid 20%. Both are available in azelaic Acid gel and azelaic Acid foam.

And we have a pretty good idea that both are effective: A systematic review of the clinical trials of both concentrations published in 2006 in JAMA Dermatology included data from five studies (873 participants). Researchers concluded that both azelaic acids 15% and 20% were effective in treating rosacea, particularly the pustules and papules. “The other common symptoms – persistent flushing and visible blood vessels -are notoriously difficult to manage without laser treatments,” says John G. Zampella, MD, assistant professor in the Ronald O. Perelman Department of dermatology at NYU Langone Health.

The azelaic acid 20% formulation has already been greenlighted for the treatment of acne, but a 2018 study in the Journal of Drugs in Dermatology suggests that the azelaic acid 15% formulation is also effective and safe in treating moderate to severe acne. The 20 participants in the study experienced mild dryness and skin peeling, but these side effects were resolved by the end.

These prescription options for azelaic acids are not always available. Dr. Zampella says that insurance is becoming more difficult to cover these prescriptions. Azelaic acid prescriptions without insurance can be quite expensive, Dr. Ogunleye said. Usually, it costs a few hundred dollars. Your dermatologist might recommend an over-the-counter product containing azelaic acids if your insurance does not cover it. This brings us to…

What are nonprescription azelaic acid products?

There are many options, but there isn’t enough evidence to show that they improve acne or rosacea. The Ordinary offers a 10% azelaic acids suspension. The price of a prescription for azelaic acids is much lower than the $10 cost of this suspension. Dr. Ogunleye will often recommend to patients that they look online for over-the-counter alternatives if their prescription isn’t covered by insurance. You can also find Paula’s Choice Boost 10% Azelaic Acid Booster online. This product costs $36, but it also contains salicylic acids (but this may not be the best option if your skin is sensitive or prone to flaking from acne treatments).

There’s not much research on these concentrations (and none on the specific products above), but there is one study, published in 2014 in the Journal of Medical Sciences, that showed promise for a lower-than-prescription concentration. The researchers looked at 40 people with mild to moderate acne. Half received 10% azelaic acids gel, while the other half received it in an alcohol-based base. Eight weeks later, both the severity and frequency of acne in each group decreased significantly. However, there was no difference between the groups. This suggests that a 10% concentration could be beneficial for acne.

However, this study has some drawbacks, such as the small sample size and lack of a control group. Also, it was not possible to compare the results with azelaic acids 15% or 20% concentrations.

These options may not be as efficient as prescription ones, but Dr. Ogunleye suggests they are worth a try. Dr. Massick also agrees that although they are less potent than azelaic Acid 15% or azelaic Acid 20% concentrations, 10% is a good starting point and a fair price for azelaic acids. Dr. Zampella says, “If we can’t get a prescription-strength covered, my general approach is to have a patient attempt the 10%.” He says that Azaic acid is “one of the safest medications you could try,” so the benefits often outweigh any potential risks.

Is azelaic Acid safe for pregnant women?

Unlike some acne treatments (including retinoids and benzoyl peroxide), azelaic acid is generally considered safe to use during pregnancy. The American Academy of Dermatology states that there is no research on pregnant women, but animal studies suggest that it does not cause birth defects. Dr. Massick states that there is minimal fetal exposure when azelaic acids are applied topically. “Azelaic acid is absorbed less than 4% by the skin when it is applied topically.” It is smart to consult your doctor if azelaic acid is right for you.

What is the time it takes for azelaic acids to start working?

Dr. Zampella recommends that you use azelaic acids to treat acne or rosacea for at least three months. After that, you can decide if it is working for you. Some people see results in as little as four to six weeks, while others may notice a difference in as much time as six weeks. He says that if you are using it to treat pigmentation issues, some people notice a difference within one week.

Azelaic acids can be used long-term as an everyday product. Dr. Shirazi suggests applying it after cleansing your skin in the morning and night. Dr. Shirazi states that azelaic acid should be used long-term for patients with rosacea, chronic acne or melasma, and sensitive skin. It’s safe and effective in long-term acne treatment. However, it might not be the best choice for occasional breakouts. She says that although it isn’t as potent as retinol, it is gentler for sensitive skin.

You won’t have any problems if you miss a morning or evening dose. However, it is best to be consistent and remember to apply the dose whenever you remember. Dr. Massick warns that it may not be as effective if it isn’t used consistently.

While your skin adjusts to azelaic acids, it is a good idea not to use harsh or potentially irritating products. It is also a good idea not to use too many exfoliating products at once to minimize irritation. Although you can technically use azelaic acids with a physical exfoliant such as a facial scrub or a scrub, Dr. Shirazi warns that you shouldn’t use them all together. You could end up with too much skin peeling off and irritation if you use all of these options.

Dr. Zampella states that azelaic acid is a relatively easy ingredient. And there isn’t really anything you can never use it with, Dr. Ogunleye adds, although it’s always smart to ask your derm about potential problems with ingredient combinations. Dr. Zampella states that insurance is the biggest obstacle to getting coverage.

Talk to your dermatologist if you have questions about azelaic acids or if you are eligible for a prescription. There are also 10% over-the-counter options that, according to the doctors we spoke to, are a good and affordable place to start.

How can you get started with azelaic Acid?

Dr. Zampella states that acid treatments, particularly those for acne, can be quite harsh. However, most people, even those with sensitive skin or rosacea, are able to use azelaic acids with minimal discomfort. It can cause irritation, as with all acids, but it usually disappears over time. Dr. Massick says that Azaic acid is less irritating than retinoid or benzoyl peroxide. It won’t bleach clothes the same way benzoyl peroxide does, and it won’t cause dryness, irritation, or peeling in the same way as a retinoid.

Dr. Zampella recommends that you start slowly when applying azelaic acids for the first time. To avoid any mild irritation, apply a small amount to the inside of your arm and do a patch test. If your skin is not irritated after 24 hours, then you can apply a thin layer to your face twice daily or as directed by your doctor. Dr. Ogunleye suggests that you only use it for affected skin.

You should seek medical attention if you experience itchiness, burning, or stinging that does not go away. A very rare but severe allergic reaction can manifest in such symptoms as swelling, a rash, or difficulty swallowing.

Experts who spoke to us recommended using azelaic acids in place of other acne-fighting ingredients like retinol and salicylic acid. Too many treatments can cause skin irritations, which is why azelaic Acid is recommended. However, you can combine it with other gentler skin-care active ingredients like niacinamide – a form of vitamin B3 that can also .potentially treat acne and rosacea – or in conjunction with ceramides, Dr. Shirazi adds.

Another thing to remember: Once you begin using azelaic acid, it is important to keep it at room temperature. Dr. Massick warns that extreme temperatures could cause the medication to lose its effectiveness. Azelaic Acid foam is more flammable than other formulas so it should be kept away from heat.

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