BENEV Azalex Gel contains 10% azelaic acid over-the-counter. Photo courtesy Amazon.com.
Azelaic acid (like kojic acid) is a bleaching agent that is commonly used in alternating four-month cycles with hydroquinone (Cosmetic Dermatology). Azelaic acid has also been found to be effective as an acne treatment, and, to a lesser extent, a rosacea treatment. However, how effective is azelaic acid? Could you use it instead of hydroquinone? And is it safe? For these answers and more, read on.
How effective is azelaic acid as a bleaching agent?
According to a double-blind study in the International Journal of Dermatology, over the treatment period (24 weeks), a 20% azelaic acid cream yielded 65% good or excellent results. In fact, 20% azelaic acid had “no significant treatment differences” observed when compared to 4% hydroquinone (the prescription level) with regard to overall rating, reduction in lesion size, and pigmentary intensity. Side effects, such as allergic sensitization or exogenous ochronosis (associated with hydroquinone) were not observed with 20% azelaic acid.
Should I consider azelaic acid over hydroquinone if I have dark skin?
Yes (i.e., typically Hispanic or Black skin tones). Ochronosis, a darkening of the skin that is caused by a build-up of phenylalanine or tyrosine, has been linked to hydroquinone use, but primarily in those with darker skin. In fact, according to the American Journal of Clinical Dermatology, the majority of patients with ochronosis are Black, but it has been reported to occur in Hispanics and Caucasians as well. Exogenous ochronosis is prevalent among South African Blacks, but is relatively uncommon amongst this population within the U.S. As such, those of African-American descent may wish to take extra precautions in avoiding products with resorcinol and excessive sun exposure when using hydroquinone products.
Can azelaic acid be used to treat acne?
Yes. According to a 1996 study in the journal Cutis (Cutaneous Medicine for the Medical Practitioner), 20 percent azelaic acid alone is effective in mild to moderate forms of acne, with an overall efficacy comparable to that of tretinoin (0.05 percent), benzoyl peroxide (5 percent), and topical erythromycin (2 percent). For moderate to severe acne, 20 percent azelaic acid may be favorably combined with minocycline with 90 percent good/excellent results, and may contribute towards reducing recurrences following discontinuation of systemic therapy (maintenance therapy with azelaic acid). Further, according to this 1989 study, 20% azelaic acid cream was not only equally as effective as 0.05% tretinoin cream, but was also better tolerated, causing fewer local side effects than the topical retinoid.
Can azelaic acid be used to treat rosacea?
Yes, and significantly so. According to a 1999 double-blind, randomized, multicenter study in Acta Dermato-Venereologica, treatment with 20% azelaic acid twice daily for 3 months resulted in significantly more favorable overall improvements than vehicle in both physician and patient ratings. In addition, more than 90% of patients rated the overall local tolerability of their treatment as good or acceptable. In addition, a separate study in the Archives of Dermatology found that 15% azelaic acid was significantly more effective than 0.75% metronidazole in improving the inflammatory lesions and erythema of rosacea.
A side note: Does hydroquinone (an azelaic acid bleaching alternative) really cause cancer?
Hydroquinone is currently the most commonly used bleaching agent in the United States. Although it is a metabolite of benzene and therefore exhibits potential carcinogenic properties, most studies that suggest a link between hydroquinone and cancer are those in which hydroquinone is applied in impractically high concentrations. In fact, according to Dr. Susan C. Taylor, M.D., a Philadelphia-based dermatologist in the October 2007 issue of Elle magazine,”The maximum levels of hydroquinone currently allowed (2 percent for over the counter, 4 percent for prescription) aren’t dangerous. At worst, it might cause redness or irritation, but only if your skin is sensitive or allergic to the medication.” Dr. Leslie Baumann further adds in Cosmetic Dermatology, “The most serious human health effect seen in workers exposed to hydroquinone is pigmentation of the eye and, in a small number of cases, permanent corneal damage.”
In what products is azelaic acid found?
20% azelaic acid is available by prescription only in Azelex. 15% azelaic acid is also available by prescription only in Finacea. Over-the-counter, the best product I could find, with 10% azelaic acid, is BENEV Azalex Gel ($80.00, Amazon.com). Although SD alcohol 40 is the main ingredient (never a good thing), it also contains more hydrating glycosaminoglycans, glycerin, and butylene glycol. I do wish the product didn’t contain the alcohol, though! A second excellent product is Mychelle Clear Skin Serum ($23.25, Amazon.com), which contains a seemingly high unspecified concentration of azelaic acid, and also niacinamide and retinol. Unfortunately, Mychelle Clear Skin Serum also contains low-molecular weight alcohols, which can be drying, and ylang-ylang/patchouli essential oils, which may make some individuals break out. At any rate, these are two sources of azelaic acid available over-the-counter.
Overall…
I love azelaic acid! Research shows 20% azelaic acid to have the bleaching efficacy of prescription-strength hydroquinone, without the negative side effects for darker skins. Research has also shown acne-fighting effects similar to prescription-strength tretinoin (and we all know how I love tretinoin!) Finally, the ingredient helps some signs of rosacea. I give this ingredient an enthusiastic thumbs-up, and will post as more companies release over-the-counter products with more azelaic acid.