Does azelaic acid help with acne? What trials show

Azelaic acid helps mild to moderate acne, and it also fades the dark marks acne leaves. The American Academy of Dermatology (AAD) describes it this way: "This acne treatment opens clogged pores and helps keep them open, works on the bacteria that cause acne, and reduces inflammation due to acne." The trials show a steady, moderate effect. In head-to-head studies it matched tretinoin, a prescription retinoid, and did less than benzoyl peroxide. This guide covers how it works on acne, what the trials found, where the guidelines place it, and how to use it. For what azelaic acid is and its other uses, see what azelaic acid is.

How azelaic acid works on acne

Acne starts in the pore. Skin cells and oil build up and form a plug, bacteria grow inside it, and the skin around it becomes red and swollen. Azelaic acid acts on three of these steps.

• The plug. The FDA label for azelaic acid 20% cream says "a normalization of keratinization leading to an anticomedonal effect" may explain part of its effect. In plain words, it helps the cells inside the pore shed normally, so fewer plugs form. Skin samples from people using the cream showed a thinner top layer of dead cells.
• The bacteria. The same label says lab tests show azelaic acid acts against Propionibacterium acnes, the older name for the main bacterium linked to acne. A 2024 review in Clinical, Cosmetic and Investigational Dermatology adds that, unlike antibiotics, it "does not induce bacterial resistance."
• The redness and swelling. The AAD says it "reduces inflammation due to acne."

MedlinePlus, the U.S. National Library of Medicine's drug guide, sums it up: azelaic acid treats acne "by killing the bacteria that infect pores and by decreasing production of keratin, a natural substance that can lead to the development of acne." The label adds that "the exact mechanism of action of azelaic acid is not known." The effects above come from lab tests and skin samples.

What the trials found

Study	What was compared	Result
1989, Acta Dermato-Venereologica	Azelaic acid 20% cream against the same cream without the medicine, 3 months, 92 people with red acne bumps	Azelaic acid reduced acne lesions more
1989, same paper	Azelaic acid 20% cream against tretinoin 0.05% cream, 6 months, 289 people with mostly clogged-pore acne	Equal reduction in clogged pores; azelaic acid caused fewer side effects on the skin
2020, Cochrane review of 49 trials	Azelaic acid against other acne treatments	Probably less effective than benzoyl peroxide; probably little or no difference from tretinoin
Trial of 220 people, described in a 2026 review	Azelaic acid 20% cream twice a day against benzoyl peroxide 3% with clindamycin once a day, 12 weeks	Red bumps fell by 52.6% with the combination and 38.8% with azelaic acid

The Cochrane review pooled 49 randomized trials and graded how much each result can be trusted. It found that "azelaic acid is probably less effective than benzoyl peroxide," based on one trial of 351 people, and that there is "probably little or no difference when comparing azelaic acid to tretinoin," based on one trial of 289 people. It rated both findings as moderate quality. For the comparisons with clindamycin and adapalene, the evidence sat in the two lowest quality grades.

The 2026 review in Skin Health and Disease adds the 220-person trial. There, azelaic acid cream used twice a day caused more itching, pain, redness and dryness than the once-a-day combination gel. The review suggests the twice-a-day schedule may explain part of that.

Where the guidelines place it

The 2024 AAD acne guideline gives azelaic acid a "conditional" recommendation. That means the experts judged it useful for some people, with weaker evidence than for the top treatments. The same guideline makes "strong recommendations" for benzoyl peroxide, topical retinoids, topical antibiotics and the antibiotic pill doxycycline.

NICE, which writes acne guidance for the NHS in England, uses azelaic acid in two places:

• Moderate to severe acne: "topical azelaic acid with either oral lymecycline or oral doxycycline," applied twice a day, as one of its first choices. Lymecycline and doxycycline are antibiotic pills.
• Keeping acne away after it clears: if the adapalene and benzoyl peroxide gel is not tolerated, NICE says to "consider topical monotherapy with adapalene, azelaic acid, or benzoyl peroxide," and to review it after 12 weeks.

NICE defines the product as azelaic acid at 15% or 20%. The strengths guide explains what those numbers mean and what is known about the 10% products sold in stores.

Which acne it suits

Red bumps, mild to moderate. The FDA label for the 20% cream covers "mild-to-moderate inflammatory acne vulgaris," which means acne with red, swollen bumps.

Clogged pores. The 1989 trial of 289 people studied acne made mostly of blackheads and whiteheads, and azelaic acid 20% cream reduced them as well as tretinoin did. The closed comedones guide covers the small skin-colored bumps in more detail.

Chest and back. Most trials treated the face. A 2020 case series described four women whose chest and back acne cleared with azelaic acid 15% foam and tretinoin 0.05% lotion. A case series is a report on a few patients with no comparison group, so it cannot show how most people respond. See back acne for other options.

Deep, painful lumps. For this type of acne, the sources add other treatment. NICE pairs it with an antibiotic pill for moderate to severe acne, and the 2024 AAD guideline strongly recommends isotretinoin, a prescription pill, for acne that is severe or leaving scars. The cystic acne guide explains what a dermatologist can offer.

A second benefit: the marks acne leaves

The AAD says "azelaic acid can also treat the dark spots that appear when acne clears." This is the main reason Skinli's plan uses it. The plan's two acne gels do the work of clearing acne, and azelaic acid is added only for people whose photos show flat red or brown marks. The azelaic acid for dark spots guide covers that use and its trials.

How to use it for acne

The FDA label for the 20% cream gives these steps:

1. Wash the skin and pat it dry.
2. Massage "a thin film" gently into the affected areas.
3. Use it twice a day, morning and evening.
4. Wash your hands afterward.

The label also asks you to keep it away from the eyes, mouth and the inside of the nose, and not to cover the skin with a bandage. Products sold in stores come with their own directions, and those can differ, so read the box.

Skinli's 12-week plan uses azelaic acid 10% cream once a day, in the morning, from week 5, before sunscreen, and only for people with flat marks. The acne gels, adapalene 0.1% and benzoyl peroxide 2.5%, go on at night. The free Skinli acne plan builds this routine from a photo and tells you when a doctor is the better next step.

If you want to combine azelaic acid with other acne products, a 2000 paper in the Journal of the American Academy of Dermatology reported better results in combination with benzoyl peroxide 4% gel, clindamycin 1% gel or tretinoin 0.025% cream. Add one new product at a time. The guide to azelaic acid with tretinoin covers that pair.

Side effects

The label says itching, burning, stinging and tingling were the most common reactions in the U.S. trials of the 20% cream, each seen in 1% to 5% of patients. Redness, dryness, rash and peeling were each seen in less than 1%. It says the stinging comes "in part" from the low pH of azelaic acid, meaning it is acidic, and that it "commonly subsides if treatment is continued."

The label has one warning to take seriously if you have darker skin. There have been "isolated reports of hypopigmentation," meaning patches lighter than the surrounding skin. Because azelaic acid "has not been well studied in patients with dark complexions," the label says these patients should be watched for early signs. Report any change in skin color to a doctor.

Some people wonder whether azelaic acid makes acne worse before it gets better. The purging guide looks at what the labels and trials report.

How long to give it

The 20% cream label says: "Improvement of the condition occurs in the majority of patients with inflammatory lesions within four weeks." The AAD and NICE give longer timelines. The AAD says that for acne treatment in general "it takes at least 6 to 8 weeks before you start to see fewer breakouts," and NICE plans each course for 12 weeks. Skinli's plan allows 8 to 12 weeks for skin to change. The before and after guide sets out what each trial measured and when.

When to see a doctor

See a doctor or dermatologist if your acne is painful, forms deep lumps, leaves scars, or has not improved after 12 weeks of steady care. See one sooner if you notice light patches, if the stinging does not settle, or if your face swells. The 15% and 20% products need a prescription in the U.S., so a doctor is also the way to get them. The best acne treatments guide compares azelaic acid with the other options a doctor may offer. Skinli gives general education. A doctor is the right person to diagnose and treat your skin.