Azelaic acid for perioral dermatitis: the evidence

Perioral dermatitis is a rash around the mouth, and azelaic acid is one of several creams doctors have tried for it. The evidence is limited and mixed. A small study in children found the rash cleared with azelaic acid cream, while a 2022 systematic review found that azelaic acid gel may make no difference after 6 weeks. The FDA labels for azelaic acid cover acne and rosacea, so using it for this rash is a decision a doctor makes. This guide sets out what the studies found, what the American Academy of Dermatology (AAD) says to do first, and how to use azelaic acid safely if a doctor prescribes it. For the ingredient itself, see what azelaic acid is.

Perioral dermatitis is a medical condition. Skinli cannot diagnose it, and a rash around the mouth can have other causes. See a doctor to confirm what it is.

What perioral dermatitis is

The AAD describes it as a rash that "often looks like small, red, acne-like breakouts in people with light-colored skin and skin-colored breakouts in people who have skin of color." It can itch or burn, and the skin is often dry and flaky. Despite the name, it can also appear around the eyes or nose. The AAD says it cannot spread from person to person.

On the cause, the AAD says "it's not entirely clear what causes this rash." It names three possibilities:

• A skin care product or toothpaste that irritates the skin.
• An allergy to something that touches the skin.
• A corticosteroid cream used on the skin for too long. The AAD says "many people develop this rash" this way.

A 2021 review in the Journal of Cosmetic Dermatology reached the same point from the research side: it found "the strongest evidence to support topical corticosteroid misuse as the principal causative factor."

The first step: stop steroid creams

Before any cream is added, the AAD's advice is to take one away: "To clear perioral dermatitis, you must stop applying all corticosteroids, including hydrocortisone cream, to your skin." If a doctor prescribed the steroid, ask that doctor before stopping.

The AAD warns that the rash can flare after you stop: "When you stop applying a corticosteroid or hydrocortisone cream, the rash can worsen. If this happens, it can be tempting to start using the cream or ointment again. Don't." Going back to the steroid "will only bring temporary relief."

The AAD also suggests changing your skin care: switch to a mild, fragrance-free cleanser, wash your face gently, and use fragrance-free products.

What the studies found for azelaic acid

Study	Who	What was used	Result
2022 systematic review, Journal of the European Academy of Dermatology and Venereology	11 studies, 733 children and adults	Several treatments, including azelaic acid gel	Azelaic acid gel "may result in no change" in severity after 6 weeks, as rated by doctors or patients
2010 study, Pediatric Dermatology	10 children aged 3 to 12, all of whom had used steroid creams on the face	Azelaic acid 20% cream twice a day	The rash cleared in all 10 after 4 to 8 weeks; 3 had a short flare at the start
2021 review, Journal of Cosmetic Dermatology	Published research	Treatments in use	Tetracyclines, topical metronidazole, topical azelaic acid, adapalene gel and isotretinoin all need more research

The 2022 review is the strongest evidence, because it pulled together every study its authors could find and graded them. It rated the whole body of evidence for perioral dermatitis treatments as low certainty or lower. So the finding for azelaic acid is uncertain, and so are the findings for the other treatments.

The 2010 study is encouraging, and it has two limits. It had 10 patients, and it had no comparison group. Perioral dermatitis can clear on its own once steroid creams stop, which the AAD mentions ("while this rash may clear on its own, some people need a dermatologist's help"). Without a comparison group, the study cannot show how much of the improvement came from the cream.

A 2024 review in Clinical, Cosmetic and Investigational Dermatology lists perioral dermatitis among the conditions where azelaic acid use has been reported, and gives no trial results for it.

What dermatologists use

The AAD lists what a dermatologist may do:

• Stop all corticosteroids, including hydrocortisone cream.
• Prescribe an antibiotic, "such as tetracycline or erythromycin."
• Change your skin care routine.

It adds: "While many patients receive an antibiotic, you may need a different medication," and "in some cases, a patient may need to use a mild corticosteroid cream for a while along with other medication." The 2022 review found low-certainty evidence that tetracycline pills may improve the rash from day 20 onward, and that pimecrolimus cream may give a small improvement after 4 weeks.

The studies above show azelaic acid is among the other medicines that have been tried. The choice belongs to the doctor.

If a doctor prescribes azelaic acid

The FDA labels for the 15% gel and the 20% cream give directions that also apply here, with extra care because of where this rash sits:

1. Wash with a mild soap or a soapless cleansing lotion and pat dry.
2. Apply a thin layer to the rash, twice a day, unless your doctor says otherwise. The children in the 2010 study applied 20% cream twice a day to all affected areas until the rash cleared.
3. Keep it off the lips and out of the mouth, nose and eyes. The labels say to avoid contact with "the eyes, mouth and other mucous membranes," which is the moist skin inside the mouth and nose. If it gets in your eyes, rinse with plenty of water.
4. Wash your hands afterward.
5. Do not cover the area with a bandage.

Cold sores. The labels report that cold sores flared again in some people using azelaic acid. MedlinePlus says to tell your doctor if you "have or have ever had asthma, or cold sores that keep coming back."

Burning, stinging and early flares

Azelaic acid often stings at first. The 15% gel label reports burning, stinging or tingling in 29% of trial users with rosacea, and says irritation usually happens "during the first few weeks of treatment." The 20% cream label says irritation is most likely when the cream is applied "to broken or inflamed skin, usually at the start of treatment," and that it "commonly subsides if treatment is continued."

That matters here, because the skin of perioral dermatitis is already inflamed, and the AAD says the rash itself can burn. In the 2010 study, 3 of 10 children had a short flare that peaked between the 2nd and 6th day, and 6 had side effects, mostly in the first 2 weeks. The authors describe these side effects as minimal.

Stop and see your doctor if the burning is strong, if it does not ease after the first weeks, if the rash spreads, or if your face swells. The purging guide explains how to tell a short flare at the start from a reaction.

Store products and treating it yourself

Products sold without a prescription contain azelaic acid, typically at lower strengths and often mixed with other ingredients, according to the 2024 review. No study Skinli found tested them for perioral dermatitis. Some also contain fragrance, and the AAD advises fragrance-free products for this rash. The AAD's skin care advice for this rash is short: a mild, fragrance-free cleanser, gentle washing and fragrance-free products. The gel, cream or serum guide explains how the forms differ.

How long it takes

The AAD says to "expect gradual improvement. This rash tends to clear slowly. It may take a few weeks or a few months to clear completely." In the 2010 study, the rash cleared after 4 to 8 weeks with azelaic acid cream, 5.4 weeks on average. No child had the rash return in the 2 to 8 months of follow-up.

Perioral dermatitis and rosacea

Both conditions can cause red bumps on the face, and the AAD describes both as acne-like. Azelaic acid 15% gel and foam are FDA-approved for the bumps of rosacea. The azelaic acid for rosacea guide covers that approved use, and a doctor can tell the two conditions apart.

When to see a doctor

See a doctor or dermatologist for any rash around the mouth, nose or eyes that lasts more than a few days, and before you stop a prescribed steroid cream. See one sooner if the rash is near the eyes, affects a child, spreads, or keeps coming back. A doctor can confirm the diagnosis and choose between an antibiotic, azelaic acid or another medicine. Skinli gives general education. A doctor is the right person to diagnose and treat your skin.