What is azelaic acid? Benefits, uses and risks

Azelaic acid is an acid that occurs naturally in whole grains, in animal foods and in the body, and it is used for acne, rosacea bumps and dark marks. The American Academy of Dermatology (AAD) describes its effect on acne this way: it "opens clogged pores and helps keep them open, works on the bacteria that cause acne, and reduces inflammation due to acne." The FDA has approved it as a prescription medicine at two strengths: 20% cream for mild to moderate acne, and 15% gel and foam for the bumps of rosacea. Lower strengths are sold in stores as skin care. This guide explains what azelaic acid is, what it does, how strong the evidence is for each benefit, and what the risks are. Each topic has its own detailed guide in this section.

Skinli gives general education. A doctor is the right person to diagnose and treat your skin. The prescription strengths need a doctor, and rosacea and other rashes need a diagnosis.

What azelaic acid is

The FDA label for the 20% cream calls azelaic acid "a naturally occurring saturated dicarboxylic acid." In plain words, it is a chain of nine carbon atoms with an acid group at each end. MedlinePlus, the U.S. National Library of Medicine's drug guide, says it "is in a class of medications called dicarboxylic acids." That family is separate from the alpha and beta hydroxy acids, such as glycolic and salicylic acid. The guide is azelaic acid an exfoliant explains the difference.

It comes from several places:

• Food. The label says it is "a dietary constituent (whole grain cereals and animal products)."
• The body. The label says it "can be formed endogenously," meaning the body makes it.
• Skin yeast. A 2024 review in Clinical, Cosmetic and Investigational Dermatology says a yeast that normally lives on the skin, Malassezia, produces it.

The same review tells how dermatology found it. In the 1970s, a dermatologist in Rome noticed pale patches in a yeast rash of the skin. Researchers traced them to this yeast, which breaks down fats into acids, including azelaic acid, that slow pigment cells. The labels give 1995 as the year azelaic acid was first approved in the U.S., and the review says the FDA approved it for rosacea bumps in 2002.

What it does in the skin

The 20% cream label states the limits plainly: "The exact mechanism of action of azelaic acid is not known." The 15% gel label says the same for rosacea. What the labels and reviews describe:

Action	What the source says	Why it matters
Works on acne bacteria	The label says lab tests show "antimicrobial activity against Propionibacterium acnes," the older name of the main acne bacterium	Fewer bacteria, fewer red bumps
Keeps pores from plugging	"A normalization of keratinization leading to an anticomedonal effect," per the label	Fewer blackheads and whiteheads
Calms inflammation	The AAD says it "reduces inflammation due to acne"	Less redness and swelling
Slows pigment	The 2024 review says it blocks tyrosinase, an enzyme skin needs to make melanin, and acts on overactive pigment cells	Fades dark marks and patches

Much of this comes from lab and skin-sample studies. The 2024 review adds that, unlike antibiotics, azelaic acid "does not induce bacterial resistance."

The benefits, and the evidence behind each

Benefit	Strength of evidence	Main sources	Guide
Rosacea bumps	High: FDA-approved at 15%; many trials	2019 review in the British Journal of Dermatology found high-certainty evidence	Azelaic acid for rosacea
Acne	Moderate: FDA-approved at 20%; conditional recommendation from the AAD	2020 Cochrane review; 2024 AAD guideline	Azelaic acid for acne
Acne marks, red and brown	Small trials	2024 trial of 72 people with 15% gel	Azelaic acid for dark spots
Melasma	Several trials of 20% cream	2023 systematic review	Melasma
Perioral dermatitis	Weak and mixed	2022 systematic review found the gel may make no difference	Azelaic acid for perioral dermatitis
Wrinkles and skin aging	None	2023 systematic review found no qualifying trials	This guide, below

Rosacea. This is where the evidence is strongest. In two 12-week trials on the 15% gel label, bump counts fell from 17.5 to 6.8 and from 17.9 to 9.0, against 17.6 to 10.5 and 18.5 to 12.1 with the same gel without the medicine. The 2019 review found "high-certainty evidence for topical azelaic acid and topical ivermectin" for rosacea bumps. The labels say its effect on redness without bumps has not been evaluated.

Acne. The 2020 Cochrane review, which pools trials and grades how far the results can be trusted, found azelaic acid "probably less effective than benzoyl peroxide" and "probably little or no difference when comparing azelaic acid to tretinoin," both on moderate-quality evidence. The 2024 AAD acne guideline gives it a "conditional" recommendation, below the "strong" recommendations for benzoyl peroxide, topical retinoids, topical antibiotics and doxycycline. NICE, which writes acne guidance for England, includes topical azelaic acid with an antibiotic pill among its first choices for moderate to severe acne.

Acne marks. The AAD says azelaic acid "can also treat the dark spots that appear when acne clears." In a 2024 trial, 15% gel twice a day reduced red marks more than a plain gel by week 8 and brown marks by week 12.

Melasma. The AAD says a dermatologist may prescribe "a medication that's gentler on your skin like azelaic acid, kojic acid, or vitamin C" for melasma. A 2023 systematic review in the Journal of Cosmetic Dermatology found 20% azelaic acid worked better than a cream without the medicine in melasma trials. Its authors work for Dermatica Ltd, a UK company, and readers should know that when judging the result.

Wrinkles. The same 2023 review searched for randomized trials of azelaic acid for skin aging and found "no eligible RCTs." A 2025 survey of 62 dermatologists in the Journal of the American Academy of Dermatology agreed on azelaic acid for acne and dark spots, and on retinoids and vitamin C for fine lines and wrinkles.

Prescription and store products

Product	Strength	FDA-approved for	Prescription in the U.S.
Cream	20%	Mild to moderate acne	Yes
Gel	15%	Rosacea bumps	Yes
Foam	15%	Rosacea bumps	Yes
Store creams and serums	Usually lower	Nothing	No

The 2024 review says store products usually contain less azelaic acid and often combine it with other ingredients. The research on them is small. The strengths guide compares 10%, 15% and 20%, and the gel, cream or serum guide compares the forms.

How it is used

The prescription labels give the same basic steps: wash with a mild cleanser, pat dry, apply a thin layer to the affected areas twice a day, and wash your hands afterward. The gel and foam labels say makeup can go on once the product has dried. All three labels ask users to avoid alcohol-based cleansers, astringents, scrubs and peeling agents, and to keep the product away from the eyes and mouth.

Skinli's 12-week plan uses azelaic acid 10% cream for people whose photos show flat red or brown acne marks. It goes on once a day in the morning, from week 5, after moisturizer and before sunscreen. The acne gels, adapalene 0.1% and benzoyl peroxide 2.5%, go on at night. The free Skinli acne plan decides from a photo whether the mark cream is needed.

For step-by-step use with a retinoid, including morning and night timing, see azelaic acid with retinol. For other pairings, see azelaic acid with tretinoin and azelaic acid with niacinamide.

Where it fits in a routine

Azelaic acid is one step in a routine, and its place depends on what else you use. This is how Skinli's 12-week plan fits it in for people with flat acne marks:

Time	Steps
Morning	Gentle cleanser, moisturizer, azelaic acid 10% cream (from week 5), sunscreen
Night	Gentle cleanser, the acne gels (adapalene 0.1% and benzoyl peroxide 2.5%), moisturizer

The plan starts the acne gels first and adds azelaic acid four weeks later, so that if your skin reacts, you can tell which product caused it. Putting azelaic acid in the morning keeps it apart from the night-time retinoid. If a doctor prescribed azelaic acid 15% or 20% for twice-daily use, follow the prescription instead.

Side effects and warnings

Most side effects happen on the skin where it is applied, and most come early:

• Stinging, burning, tingling and itching. The 15% gel label reports burning, stinging or tingling in 29% of trial users with rosacea and itching in 11%, usually "during the first few weeks of treatment." The 20% cream label reports these in 1% to 5% of acne trial users and says the irritation, caused "in part" by the acid's low pH, "commonly subsides if treatment is continued."
• Dryness and scaling. The gel label reports dry or scaly skin in 8% of users.
• Light patches. All three labels report "isolated" cases of skin lightening. Because azelaic acid "has not been well studied in patients with dark complexion," the labels ask these patients to watch for early signs.
• Eyes. It can irritate the eyes. Rinse with plenty of water if it gets in.
• Asthma. The gel label says "worsening of asthma has been reported."
• Cold sores. The labels report flares of cold sores in some users. MedlinePlus says to tell your doctor if you have asthma or "cold sores that keep coming back."
• Allergic reactions. The gel label reports swelling of the face and eyes, hives and trouble breathing after approval. Stop and get urgent care if these happen.

The gel label also says no reactions to sunlight were reported in its human safety studies. The purging guide explains what the first weeks look like, and whether acne can get worse before it improves.

Azelaic acid on darker skin

A 2010 review in the Journal of Clinical and Aesthetic Dermatology says dark marks after inflammation are common and that the problem "tends to affect darker skinned patients with greater frequency and severity." Azelaic acid is one of the options for them. The AAD says azelaic acid "can also treat the dark spots that appear when acne clears." A 2026 review in Skin Health and Disease says U.S. guidelines recommend using azelaic acid for these marks in people with darker skin types.

The labels add a caution in the other direction. There have been isolated reports of lighter patches after azelaic acid, and the labels say it "has not been well studied in patients with dark complexion." Both facts matter: azelaic acid can fade marks, and you should watch for new pale patches. Monthly photos in the same light make both changes easier to see. Skinli's guide to dark spots on darker skin covers other cautions.

Who should be careful

• People with darker skin, because of the reports of light patches. Take a photo each month and report any change in color.
• People with asthma or frequent cold sores, who should tell their doctor first, as MedlinePlus advises.
• Children. The 15% gel label says safety and effectiveness have not been established in children, and the 20% cream label says the same for children under 12.
• Pregnant or breastfeeding people. The AAD says azelaic acid "is thought to be safe to use during pregnancy." The pregnancy guide sets out what the labels say. Ask your doctor or pharmacist first.
• People with a facial rash they have not had diagnosed. Rosacea and perioral dermatitis can look like acne. The AAD says a dermatologist diagnoses rosacea "by examining your skin and eyes."

How long it takes

Azelaic acid works slowly. The 20% cream label says most people with red acne bumps improve within four weeks. For rosacea, the gel label says to reassess the diagnosis if there is no improvement after 12 weeks. For marks, the 2024 trial saw no difference from a plain gel at week 4, and a difference by weeks 8 and 12. The before and after guide collects every timeline and explains how to track your own.

Keeping results

Acne and rosacea are long-term conditions, so researchers have tested azelaic acid for keeping skin clear after treatment. NICE lists topical azelaic acid alone as an option to keep acne away when the adapalene and benzoyl peroxide gel is not tolerated, with a review after 12 weeks. For rosacea, the 2019 review found that azelaic acid 15% gel, topical metronidazole and ivermectin "seem effective and safe as maintenance treatments." New acne can leave new marks, so steady acne care and daily sunscreen protect the results you get.

How it compares with other acne and mark treatments

Ingredient	2024 AAD acne guideline	2025 dermatologist survey agreed on
Benzoyl peroxide	Strong recommendation	Acne, oily skin
Topical retinoids (adapalene, tretinoin)	Strong recommendation	Acne, dark spots, fine lines and wrinkles, large pores, oily skin
Azelaic acid	Conditional recommendation	Acne, dark spots
Salicylic acid	Conditional recommendation	Acne, oily skin
Niacinamide	Not in the guideline summary	Redness, dark spots

A 2026 review in Skin Health and Disease says skin care ingredients such as retinol, niacinamide and azelaic acid "may be most beneficial for patients with mild-to-moderate acne, sensitive skin or those unable to tolerate prescription treatments." NICE calls azelaic acid with an antibiotic pill "a good alternative for people who have irritation to topical retinoids." For a wider comparison, see the guide to the best acne treatments.

When to see a doctor

See a doctor or dermatologist if your acne is painful or deep, leaves scars, or has not improved after 12 weeks of steady care. See one if you have facial redness or bumps that may be rosacea, or a rash around the mouth. Stop azelaic acid and get advice if stinging is severe or does not settle, if you notice light patches, or if asthma or cold sores flare. Get urgent care for swelling of the face or trouble breathing. For rosacea treatment beyond azelaic acid, see how to treat rosacea. Skinli gives general education. A doctor is the right person to diagnose and treat your skin.