Azelaic acid can be sued to treat acne

The wide use of topical antibiotics in the past has lately resulted in a big increase in bacterial resistance against these drugs. Reducing bacterial resistance to topical antibiotics is now one of the main aims with acne therapy. With this end in view, antibiotics are now being used for only short periods in combination with retinoids and antimicrobials such as benzoyl peroxide and azelaic acid.

Azelaic acid

Azelaic acid is a naturally occurring saturated decarboxylic acid that was first tried out in the 1970s in Europe as a treatment for hyperpigmentation of the skin. By chance it was also found to be an effective medication for acne. Various studies have confirmed this finding. These studies have also established that its efficacy in treating a number of skin problems including, comedonal, as well as, inflammatory acne lesions, is equal to other topical medications. Limited studies show that it works as well as oral tetracycline without any of its side effects. It is now considered an antimicrobial and it is recommended for treating mild to moderate acne, that is, both comedonal and inflammatory acne. However, it is mostly recommended as a second line of treatment.

The mechanism by which it acts is not known as yet, but it has been shown to exhibit antibacterial and anti-keratinizing properties. Its antibacterial properties reduce bacteria in the follicle. It works, it seems, partly by reducing the production of bacteria on the skin, keeping the skin pores clear and by reducing the production of keratin which is a natural substance that may lead to development of acne. It returns to normal the disordered growth of skin cells lining the follicle. Azelaic acid works well on acne caused by bacteria but has no effect on acne that is not infected by bacteria.

Azelaic acid does not cause bacterial resistance. Also, unlike benzoyl peroxide, azelaic acid does not bleach or stain normal skin or clothing. It is not photosensitive, for which reason it is particularly useful in summer time. It is also useful in patients who cannot tolerate topical retinoids. Azelaic acid helps reduce pigmentation, so it is particularly useful for dark skinned patients whose acne leaves persistent brown marks or who have cancerous melasma. However, patients with dark skin should be monitored for hypopigmentation (too little skin color). It should be used with caution in lactating or pregnant women.

Azelaic acid is applied topically and is well absorbed. It is available as a 20% cream and as a gel preparation that has been recently introduced. The normal procedure is to apply azelaic acid to the area affected by acne after thoroughly cleansing the skin. The cream is initially applied once daily and if well tolerated the application is increased to twice daily. In case of patients with sensitive skin, to begin with, azelaic acid may be applied once in two days and then the frequency gradually increased to give time to the skin to adjust. Contact with eyes should be avoided.

The response of acne to azelaic acid treatment is slow. Normally improvement is seen after one month of treatment. Continuing application of the cream shows further improvement with maximum results usually obtained after six months of continuous treatment. Treatment can be continued safely for months or years if the acne remains active.

Side effects

To date there have been no reports of serious side effects of the drug. Azelaic acid is non-toxic and fairly well tolerated with only 5% of patients having any complaints about side effects. When side effects do occur they are typically one or more of skin irritation, burning, stinging and erythema. Benzoyl peroxide and tretinoin have a higher complaint rate. Those with sensitive skin or who suffer from eczema may especially find azelaic acid irritating to apply since a mild irritant dermatitis may result.