Introducing Azelaic Acid

Most of us have at one point faced the most common of all skincare problems: acne. No less bothersome, however, is its aftereffect—the leftover brownish marks or discolorations known as post-inflammatory hyperpigmentation (PIH). The psychological distress caused by acne and PIH have been well-documented in clinical studies, confirming what many patients experience first-hand during their teenage years and beyond. A sense of embarrassment, lowered self-esteem or self-confidence, stigmatization and even the desire to socially withdraw may be all-to-familiar feelings. However, the good news is with the rapid growth and advancement in dermatologic therapies and improved access to dermatologists in the digital age, a patients’ psyche and skin no longer have to suffer.

Introducing Azelaic Acid

One of the most tried-and-true, versatile and safe topicals to fight against acne and PIH is Azelaic Acid. Found naturally in whole grains such as wheat, barley and rye, this dicarboxylic acid is also produced by a species of yeast (Malassezia Furfur) that is part of the normal skin flora. Azelaic Acid was first used in skincare nearly 40 years ago as a remedy for pigmentary conditions. Patients using it to treat hyperpigmentation coincidentally noted that it improved their acne, and hence its beneficial effect on acne was discovered. To date, Azelaic Acid has earned its place as one of the most consensually recommended prescription-strength topical agents for acne and pigmentary conditions, as well as other skin conditions.

How does it work in acne?

To understand why Azelaic Acid is effective in acne, one needs to understand the basic causes of the condition itself. In acne, excess dead skin cells build-up due to impaired shedding and these clumps of cells, along with excess oil, clog the pore. Bacteria get stuck and then overgrow inside the pore and this leads to an inflammatory cascade. The end result is a red, swollen, bump or pustule centered around a pore, commonly referred to as a blemish or pimple.

Azelaic Acid is a highly effective remedy for acne because it targets 3 (and possibly 4) of these main causative factors. First, as an acid, it stimulates regular shedding of dead skin cells and prevents pore’s from clogging. Second, Azelaic Acid has antimicrobial properties demonstrated in laboratory studies to reduce levels of P. acnes, the bacterium that plays a role in acne. Third, it has been proven experimentally that Azelaic Acid has a variety of anti-inflammatory and antioxidant effects. Finally, a few reports suggest that Azelaic Acid may reduce sebum or oil production. However, the jury is still out on this claim, as more studies are needed to support this assertion.

Azelaic Acid’s many properties and wide range of biologic activities make it beneficial in treating multiple forms of acne. Because it increases cell turnover, it is effective against comedonal acne such as blackheads, as well as the hard, white bumps trapped under the skin surface known as closed comedones. Azelaic Acid’s antibacterial and anti-inflammatory properties also allow it to target inflammatory acne; the typical red, pus-filled acne bumps.

How does Azelaic Acid work in hyperpigmentation?

Azelaic Acid has been recognized for its pigment-lightening capabilities for decades. Like hydroquinone, another well-known pigment lightener, Azelaic Acid inhibits tyrosinase, a skin enzyme that controls a key step in the production of melanin pigment. When tyrosinase is blocked, pigment cells can’t produce as much melanin, and the net result is a reduction in pigmentation or lighter skin tone. Azelaic Acid is used successfully to treat a variety of pigmentary conditions including melasma, post-inflammatory hyperpigmentation due to acne and PIH from other causes, and with slightly less potential for side effects than hydroquinone.

Are there any other benefits of Azelaic Acid?

Azelaic acid exfoliates the skin, unclogs pores, kills bacteria, reduces inflammation and even lightens pigmentation. Yet, there are more benefits, too. In one study, Azelaic Acid was found to improve the feel, smoothness and ease of application of facial foundation. Another important perk to mention is that unlike oral and topical antibiotics commonly prescribed to treat acne, there is no issue of bacterial resistance with Azelaic Acid. It is non-toxic and non-teratogenic, meaning it can be safely used in pregnancy and breastfeeding. Other agents prescribed for acne and pigmentation, such as the retinoids tretinoin and adapalene, are not considered safe for pregnancy. Finally, Azelaic Acid does not have any chromophores, meaning it does not absorb UV radiation from the sun. Therefore, you can use it in the summertime without concern that exposure to sunlight could cause an adverse skin reaction.

With so many benefits, what is the downside?

As with any medication, there is always a potential for side effects. But, Azelaic Acid has a relatively minor side effect profile, with less severe consequences than some of its other acne and pigment-fighting peers. Dryness, itching, stinging and burning are the most commonly reported side effects of Azelaic Acid.

If I can get Azelaic Acid in over-the-counter products, why do I need a prescription?

Azelaic Acid is currently on the ingredient hot list because many are starting to recognize its effectiveness and excellent tolerability profile. Over-the-counter products with low levels of Azelaic Acid are now being touted for acne or skin discoloration and may combine Azelaic Acid with other active agents. While these low concentration combination products can be safely used without a prescription straight off the shelf, they are generally regarded as less effective, and there are few to no studies that evaluate their efficacy. To obtain an optimal outcome when treating acne or hyperpigmentation, published studies demonstrate that 15-20% Azelaic Acid is the ideal concentration. Hence, to obtain the best possible result from treatment, one should obtain a prescription from a dermatologist or licensed health care practitioner.

What’s not to like about Azelaic Acid?

Nothing. Every patient has a unique history and set of skincare concerns. Before selecting the optimal topical therapy, one needs to consider the type of acne or pigmentary concern, skin type, allergies, history of prior therapies and lifestyle factors. With its varied mechanisms of action, numerous benefits, safety and excellent tolerability, Azelaic Acid is one of the most versatile and remarkable topical agents in dermatology today. It can be easily and effectively incorporated in a customized fashion into a wide range of skincare routines for effective management of acne, hyperpigmentation and a variety of other skincare concerns. Stay tuned for more on Azelaic Acid: Part II- Rosacea.

To find out more about Azelaic Acid, have a look on our ingredients page here: https://www.dermatica.co.uk/ingredients/azelaic-acid

REFERENCES

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Abad-Casintahan, F. et al. Frequency and characteristics of acne-related post-inflammatory hyperpigmentation. J of Dermatol. 2016; 43:826-828.
Hashim, P. Efficacy and Safety of Azelaic Acid 15% Foam in the Treatment of Facial Acne Vulgaris. J Drugs Dermatol. June 2018; 17(6):641-5.
Schulte, BC, et al. Azelaic Acid: Evidence-based Update on Mechanism of Action and Clinical Application. J Drugs Dermatol. Sept 2015;14(9). 964-72.
M A Sieber 1, J K E Hegel. Azelaic acid: Properties and mode of action. Skin Pharmacol Physiol. 2014;27 Suppl 1:9-17.
Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15% in the treatment of post-inflammatory hyperpigmentation and acne: a 16-week, baseline-controlled study. J Drugs Dermatol. 2011;10(6):586-590.
Szymańska, A, et al. Efficacy of 30% azelaic acid peel in the nonpharmacological treatment of facial acne. J Dermatolog. Treat. 2019 Aug 28;1-6.
Webster, G. Combination Azelaic Acid Therapy for Acne Vulgaris. JAAD. 2000;43:S47-50.
Nazzaro-Porro, M. Azelaic Acid. JAAD. 1987:17:1033-41.
Purdy, S. and DeBerker, D. Acne Vulgaris. BMJ Clin Evid. 2011; 2011: 1714.
Mazurek, K and Pierzchala, E. Comparison of efficacy of products containing azelaic acid in melasma treatment. J. Cosm. Derm. Sept. 2016;15(3).269-282.

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Originally published September 22 2020, updated September 22 2020

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